Columbia  5i!nit)ers(itp 

intt)eCitpctBf»jgark 

THE  LIBRARIES 


iHebical  Hihvavp 


CLINICAL  SURGERY 
BY  CASE  HISTORIES 

VOL.  I 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/clinicalsurgeryb01hert 


CLINICAL  SURGERY 

BY 

CASE  HISTORIES 


BY 


ARTHUR  E.  HERTZLER,  M.D.,  Ph.D.,  F.A.C.S. 

Professor  of  Surgery  in  the  University  of  Kansas;  Surgeon  to  the 

Halstead    Hospital,    Halstead,   Kansas,   and   to   St.   Luke's 

AND   TO   St.   Mary's   Hospitals,   Kansas   City,   Mo, 


VOL.  I 
HEAD,  NECK,  THORAX,  AND  EXTREMITIES 


WITH  TWO  HUNDRED  EIGHTY- FOUR  ORIGINAL 
ILLUSTRATIONS 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1921 


Copyright,  1921,  By  C.  V.  Mosby  Company 

(All  rights  resened) 


Press  of 

C.  V.  Mosby  Company 

St.  Louis,  U.  S.  A. 


PREFACE 

These  case  reports  represent,  with  few  exceptions,  patients  ob- 
served at  the  Halsteacl  Hospital.  Each  has  been  selected  because  of 
some  outstanding  point  of  interest.  Since  usually  those  experiences 
which  have  been  unfortunate  most  impress  us,  these  records  almost 
unwittingly  have  been  made  up  of  cases  in  which  some  one  has 
been  in  error  wholly  or  in  part.  They  represent,  not  achievement 
on  parade,  but  rather  the  sober  afterthought.  They  are  presented 
in  too  brief  a  form  to  convey  much  information,  but  they  are  in- 
tended to  remind  the  reader  of  possible  errors  rather  than  to  teach 
him  how  to  avoid  them,  for  most  likely  he  already  possesses  such 
information  if  he  but  thinks  of  the  possibility  at  the  right  moment. 

In  harmony  with  this  plan,  those  things  have  been  emphasized 
which  have  to  do  with  diagnosis  and  indications  for  treatment. 
Irrelevant  matters  have  been  eliminated.  In  order  that  these  points 
might  be  presented  clearly  and  concisely,  the  clinical  records  have 
been  rewritten  in  order  to  eliminate  as  much  as  possible  the  jerky, 
incomplete  sentences  incident  to  history-taking  at  the  bedside. 

A  topographic  classification,  according  to  the  chief  complaint,  has 
been  adopted  because  the  examiner  must  always  begin  with  the 
symptom  that  brings  doctor  and  patient  together,  however  little 
it  may  relate  to  the  actual  pathologic  process  that  lies  at  the  basis 
of  the  trouble. 

The  pathology  has  been  presented  with  the  greatest  possible 
brevity.  In  most  instances  it  amounts  to  little  more  than  a  state- 
ment of  opinion.  In  the  course  of  time,  however,  the  surgeon  who 
examines  each  bit  of  tissue  he  removes  is  very  likely  to  form  opinions 
that  are  reasonably  accurate  in  simple  problems.  In  those  cases  in 
which  a  difference  of  opinion  might  be  expected,  a  photomicro- 
graph has  been  appended,  which  will  permit  the  reader  to  judge  for 
himself. 

Photographs  have  been  used  wherever  possible,  because  they 
eliminate  the  personal  equation  inseparable  from  drawings.  It  is 
the  belief  of  the  author  that  these  represent  the  most  A'aluable 
feature  of  the  work. 

A.  E.  H. 

Kansas  City,  Missouri. 


CONTENTS 


VOL.  I 

CHAPTER  I 

PAGE 

Ox  THE  General  Principles  Underlying  the  Study  or  Surgical  Disease        1 
History,  6;   History  of  the  Present  Disease,   8;   History  of  Past  Dis- 
eases,  11;    Family  History,   12;   Examination,   13;    Physical   Examina- 
tions, 13;  Laboratory  Examinations,  17;  The  Diagnosis,  21;  Treatment, 
23 ;  Pathologic  Findings,  25 ;  After-course,  26. 

CHAPTER  II 

Diseases  of  the  CRANiuii  and  Contents 28 

Diseases  of  the  Cranium,  28;  Diseases  of  the  Cranial  Contents,  -46. 

CHAPTER  III 

Diseases  of  the  Face  and  Accessory  Sinuses 65 

Painful  Affections  of  the  Face,  65 ;  Tumors  of  the  Face,  78 ;  Diseases 
of  the  Accessory  Sinuses,  96. 

CHAPTER  IV 

Diseases  of  the  Mouth  and  Jaws 112 

Diseases  of  the  Lips,  112;  Diseases  of  the  Tongue,  121;  Diseases  of  the 
Jaw,  132. 

CHAPTER  V 

Diseases  of  the  Xeck 156 

Lymphatic  Tumors  of  the  Neck,  156;  Nonlymphatie  Tumors  of  the 
Xeck,  172;  Cystic  Diseases  of  the  Neck,  181;  Inflammatory  Diseases  of 
the  Xeck,  189. 

CHAPTER  VI 

Diseases  of  the  Thyroid  Gland 198 

X^ontoxic  Diseases  of  the  Thyroid,  198;  Toxic  Diseases  of  the  Thyroid 
Gland,  212. 

vi 


CONTENTS  Vll 

CHAPTER  A^II 

PAGE 

Diseases  of  the  Ceest  and  Spine 256 

Diseases  of  the  Mediastinum,  256;  Diseases  of  the  Lungs,  274;  Dis- 
eases of  the  Spine,  291. 

CHAPTER  VIII 

Diseases  of  the  Breast 310 

Nonencapsulated  Tumors,  310;  Diffuse  Affections  of  the  Breast,  339; 
Encapsulated  Tumors  of  the  Breast,  350;  Cystic  Tumors  of  the  Breast, 
358. 

CHAPTER  IX 

Diseases  of  the  Upper  Extremity .' 372 

Diseases  of  the  Shouhler  Region,  372;  Diseases  of  the  Elbow  and  Fore- 
arm Region,  387;  Diseases  of  the  Wrist,  400;  Diseases  of  the  Hand,  413. 

CHAPTER  X 

Diseases  of  the  IiO"n'EE  Extremities 430 

Diseases  of  the  Hip,  430 ;  Diseases  of  the  Thigh,  452 ;  Diseases  of  the 
Region  of  the  Knee,  474;  Diseases  of  the  Calf,  496;  Diseases  of  the 
Foot,  517. 


ILLUSTRATIONS 


FIG.  PAGE 

1.  Angioma   of  the   temple   region 29 

2.  Hemangioma  showing  a  large  number   of   deeply   staining  cells  between 

the   vessels 30 

3.  Hemangioma  of  the  great  fontanelle 31 

4.  Cavernous  hemangioma  of  the  temporal  region 32 

5.  Large  Foramina  showing  the  site  of  the  perforating  veins 33 

6A.  Necrotic  area  of  the  forehead  produced  by  a  cancer  quack's  plaster     .  35 

6B.  The  preceding   after   the   defect   was   repaired 35 

7.  Technic  of  an  operation  for  the  subcutaneous  removal  of  angiomas     .     .  37 

8.  Angioma    after    its    removal 38 

9.  Carcinoma  of  the  scalp  from  a  breast  tumor 40 

10.  Syj)hilitic    ulcerations    of    the    forehead 41 

11.  Sarcoma  of  the  scalp 44 

12.  Section  from  case  shown  in  Fig.  11,  showing  arrangement  of  cells  about 

a  blood  vessel 45 

13.  Section  of  the  liver  in  delayed  chloroform  poisoning 47 

14.  Section  through  the  jDons  in  delayed  chloroform  poisoning 48 

15.  Degeneration  of  the  liver  in  delayed  chloroform  poisoning 49 

16.  Perivascular  degeneration  in  delayed  chloroform  poisoning 50 

17.  Fat  embolism  in  the  lung  after  fracture  of  the  femur 52 

IS.  Brain    abscess    following    mastoiditis 56 

19.  Fracture  in  the  temporoparietal  region 59 

20.  A  psammoma  of  the  dura  producing  a  tumor  in  the  parietal  region     .     .  62 

21.  Slide  of  a  brain  tumor  showing  a  psammoma. 63 

22.  Direction  in  which  the  needle  must  approach  the  foramen  in   order  to 

enter  it  properly 70 

23.  Showing  technic    of   injecting    ovale   foramen 74 

24.  Direction  in  which  the  needle  should  be  passed  to  reach  the  great  occip- 

ital nerve 77 

25.  Ehinophynia  showing  the  condition  before  and  two  weeks  after  operation  79 

26.  Section  from  rhinophyma  showing  the  increase  in  the  sebaceous  glands 

and  connective  tissue SO 

27.  Wen  of  the  cheek SI 

28.  Chronic  alveolar  abscess  simulating  a  wen 82 

29.  Basal-celled  carcinoma  of  the  alag  of  the  nose 84 

30.  Beginning  basal-celled  epitheliomas   of  the  temple 85 

31.  Basal-celled  epitheliomas  beginning  as  warty  growths 86 

32.  "Warty  epithelioma,  in  front  of  the  auditory  meatus 87 

33.  Benign  cystic  epithelioma,  of  the   cheek 89 

ix 


X  ILLUSTRATIONS 

FIG.  PAGE 

34.  Cystic  cjiitlu'lionia  showing  the  cavities  and  dense  cell  masses     ....     89 

35A.  Carcinoma  of  the  cheek 90 

SoB.   Tumor,  after  excision,  showing  the  oral  part  of  the  growth     ....  90 

36.  Four  weeks  after  excision  of  carcinoma  of  the  cheek 91 

37.  Six  weeks  after  transplanting  a  skin  flap  from  the  neck  to  the  check     .  92 

38A.  Cauliflower  growth   of  the   cheek  after   excision 93 

38B.  Comjilete  cicatrization  of  tlix;  area  excised 94 

38C.  The  edges  of  the  stoma  shown  in  the  preceding  figure  were  coaptod  and 

retained  by  means  of  traction  sutures 95 

39.  Cholesteatoma.     The  picture  shows  the  dis]ilacement  of  the  eyeliall  and 

the  bulging  in  the  temple 97 

40.  Osteoma    of    tlie    frontal    sinus fl9 

41.  The  large  clear  area  shows  the  size  of  the  cavity  occupied  by  the  newly 

formed   bone 99 

42.  (A)   Osteoma  of  the  frontal  sinus  showing  bidging  of  the  temporal  sur- 

face.    (B)  Depression  of  the  roof  of  the  orbit 101 

43.  Mucocele  of  the  frontal  sinus 103 

44.  Prominence  of  the  superior  maxilla  due  to  a  carcinoma  of  tlie  antrum     .  104 

45.  Carcinoma  of  the  antrum   showing  large   cells,   some  of   which  have  re- 

tained the  intercelhdar  bridges 10.5 

46.  Sarcoma  of  the  antrum 108 

47    Osteosarcoma  of  the  antrum 110 

48.  Lymphangioma  of  the  lip 114 

49.  Hemangioma  of  the  lip 115 

50.  Keratosis    of   the   lower   lip 116 

51.  Trachina  of  the  lip 117 

52.  Early  carcinoma  of  the  lip 120 

53.  Early  carcinoma  of  the  lip 121 

54.  Lymjihangioma   of   the   tongue 122 

55.  Gumma  of  the  tongue 123 

56.  Thyroglossal  cyst  of  the  base  of  tlie  tongue 125 

57.  Carcinoma  of  the  tongue 128 

58.  Sublingual  ranula 129 

59.  Carcinoma  of  the  floor  of  the  mouth 131 

60.  Actinomycosis  of  the  jaw 133 

61.  Actinomycosis  of  the  jaw  showing  the  crater-like  openings 136 

62.  Exostosis  of  the  lower  jaw 137 

63.  Odontoid    exostoses    of    the   lower    jaw- 138 

64.  Hypertrophy  of  the  gums 139 

65.  Chronic  abscess  of  the  hard  palate 141 

66A.  Leukoplakia,    benign 143 

66B.  Leukoplakia  undergoing  malignancy 143 

67.  Dentigerous   cyst   of  the  lower   jaw 144 

68.  Syphilitic   ulceration    of    the   palate 146 

69.  Epulis  of  the  upper  jaw 147 


ILLUSTRATIONS  XI 

FIG.  PAGE 

70.  (A)   Epulis  of  the  upper  jaw  after  removal.     (B)   Epulis  of  the  upper 

jaw  before  removal 149 

71.  Epulis    of    the    upper    jaw 150 

72.  Granuloma   of   the   alveolar   border 151 

73A.  Epiilis  of  the  upi^er  jaw  which  has  extended  to  the  antrum  and  across 

the   hard   palate 153 

73B.  Slide  of  the  preceding  showing  typical  giant-celled  sarcoma  .  .  .  153 
73C.  Large  epulis  of  the  upper  jaw  involving  the  alveolar  border  and  the 

hard    palate 155 

74.  Lymphosarcoma    of    the    neck 158 

75.  Secondary  nodule  in  Hodgkin's  disease  showing  the  thinned  skin  cover- 

ing it 159 

76.  Cross  section  of  lymph  glands  in  a  case  of  endothelial  type  of  Hodgkin's 

disease 161 

77.  Endothelial  lymph  glands  from  a  case  of  Hodgkin's  disease     ....  161 

78.  Gross  appearance  of  a  degenerated  Hodgkin's  gland 162 

79.  Microscopic  appearance  of  a  degenerated  Hodgkin's  gland     ....  163 

80.  Gross  appearance  of  pocket  of  tuberculous  lymph  glands  after  removal  164 

81.  Tuberculous   lymph   glands 165 

82.  Cystic  carcinoma  of  a  cervical  lymph  gland,  metastatic  from  a  carcino- 

ma of  the  floor  of  the  mouth 167 

83.  Gross  section  of  lymph  gland 168 

84.  Microscopic  section  of  ease  in  Fig.  83,  showing  pearl  formation     .     .  169 

85.  Lymphosarcoma    of   the    submaxillary   lymph    gland 170 

86.  Lymphosarcoma   of   a   submaxillary  lymph   gland 171 

87.  Aberrant  thyroid  at  the  angle   of  the  jaw 172 

88.  Mixed  tumor  of  the  submaxillary  gland 174 

89.  Gross  section  of  mixed  tumor  of  the  submaxillary  gland 175 

90.  Mixed  tumor  of  the  submaxillary  gland 175 

91.  Mixed   tumor    of   the   parotid 177 

92.  Eecurrent   mixed    tumor    of   the   parotid 178 

93.  Slide  of  recurrent  mixed  tumor  of   the   submaxillary  gland     ....  179 

94.  Carcinoma   of    the    neck ^ 180 

95.  Gill    cleft    cyst 182 

96.  Gill    cleft    cyst 182 

97.  Eanula  bulging  beneath  the  angle  of  the  jaw 183 

98.  Schematic   representation   of   the   thyroglossal    duet 186 

99.  Wen    of    the    neck 187 

100.  Dermoid  cyst  of  the  midline  of  the  neck 188 

101.  Dermoid  cyst  of  the  midline  of  the  neck 189 

102.  Abscess  of  the  neck  due  to  infection  from  within  the  floor  of  the  mouth  190 

103.  Woody  phlegmon  of  the  neck .  193 

104.  Infection  of  the  floor  of  the  mouth  due  to  a  sialolith 194 

105.  Huge    colloid    goiter 198 

106.  Section  of  a  colloid  goiter 199 

107A.  Gross  appearance  of  a  fibrous  goiter 201 


Xli  ILLUSTRATIONS 

FIG.  PAGE 
107B.  Slide  of  the  i»roeecling  showing  tlie  large  amount  of  c-ellular  fibrous 

tissue 201 

108.  Intratracheal  thyroid 205 

109.  Goiter  in  a  case  of  diabetes  insipidus 207 

110.  (A.)   Gross  appearance  of  an  adenomatous  thyroid.      (B.)    Gross  section 

of    the    same 222 

111.  Microscopic  appearance  of  a  toxic  fetal  adenoma 222 

112.  Section  of  toxic  thyroid 224 

11.'').  The  acini  are  widely  dilated  and  the  cells  form  papillary  projections  into 

their    lumen 224 

114.  Section   of   glandular   thyroid 227 

11.5.  Slide  of  the  preceding  showing  increase  of  the  gland  acini 227 

116.  Glandular  thyroid  with  a  small  encapsulated  area  in  the  center     .     .     .  230 

117.  Slide  of  the  preceding  showing  the  encapsulated  nodule  to  be  a  fetal 

adenoma 2.30 

118.  Gross  appearance   of  nonsuppurating   thyroiditis 2.34 

119.  The  slide  shows  acini  filled  with  colloid  much  retracted  from  the  walls 

and  showing  vacuoles  in  the  substance 234 

120.  Gross  ajipearance  of  the  thyroid  showing  round  nodule  which  lay  behind 

the  trachea 237 

121.  Adenoma  with  palely  staining  cell  and  degenerated  colloid     ....  237 

122.  Section  of  a  degenerated  toxic  goiter 244 

123.  Slide  of  a  degenerated  toxic  goiter 24.5 

124A.  Papillary  formation   in  exophthalmic   goiter 247 

124B.  Cell  degeneration  and  exfoliation  in  exophthalmic  goiter 247 

125.  Temperature  curve  in  a  fatal  ease  of  exophthalmic  goiter 249 

126.  Facial  expression  of  a  pronounced  exophthalmic  goiter  case     ....  251 
12 7A.  Colloid-toxic  goiter.     The  smaller  nodule  on  the  right  is  a  displaced 

thymus 253 

12 7B.  The  thymus  nodule  shown  in  the  preceding  cut 253 

127C.  The  thymus  nodule  on  cross  section 254 

127D.  Slide  of  the  thymus  nodule  shown  in  the  preceding  figures     ....  254 

128.  A  slight  bulging  due  to  the  goiter  is  seen  above  the  sternoclavicular 

joint 257 

129.  (A)   Gross  appearance  of  the  goiter.     (B)   The  same  on  cross  section  258 

130.  Cross  section   of   a  retrosternal   dermoid 262 

131.  Slide  from   a   dermoid  of  the  mediastinum 262 

132.  Lymphosarcoma    of    the   mediastinum 264 

133.  Schematic  representation  of  the  area  of  dullness  in  a  case  of  metastatic 

carcinoma   of   the   mediastinum 266 

1.34.  Metastatic  sarcoma   of  the  mediastinum 268 

135.  Bulging  of  the  left  border  of  the  sternum  and  enlargement  of  the  cer- 

vical h-mph  glands  in  a  case  of  lymphosarcoma  of  the  mediastinum  269 

136.  Lymphosarcoma    of    the    mediastinum 270 

137.  Aneurysm   of  the   aorta 272 

138.  Gumma   of  the   sternum 273 


ILLUSTRATIONS  Xlll 

FIG.  PAGE 

139.  Transplantation  of  a  peclicled  skin  flap  into  the  thoracic  cavity  in  order 

to   obliterate   a   chronic   empyema 279 

140.  Pin  in  left  bronchus 284 

141.  Sputum  from  a  case  of  lung  abscess  showing  separation  of  sputum  into 

three  layers 286 

142.  Irritated  melanoma  of  the  shoulder 290 

143.  Spina  bifida  of  the  cervical  region 292 

144.  Spina  bifida 294 

145.  Spina   bifida   of   the    sacral   region ■ 295 

146.  Spondylitis ^ 298 

147.  Clironic  spondylitis 300 

148.  Spinal  cord  in  chronic  spondylitis  showing  plaque  in  the  dura     .     .     .  302 

149.  Chronic  spondylitis 304 

150.  Perforating  ulcer  of  the  heel  in  spina  bifida 308 

151.  Spina  bifida  showing  a  protrusion  at  the  right  border  of  the  sacrum     .  308 

152.  Small   duct   carcinoma    of   the   breast 311 

153.  Colloid  carcinoma  of  the  breast  showing  the  destruction  of  the  skin  by 

the   invading   tumor 31o 

154.  Eecurrent  nodule  in  breast 314 

155.  Metastatic  breast  carcinoma  in  region  of  the  scar 316 

156A.  Carcinoma  of  the  breast  with  axillary  contents 320 

156B.  Skin  recurrence  in  carcinoma  of  the  breast 321 

157.     Chronic  abscess   of  the  breast   simulating   carcinoma 323 

158A.  Carcinoma  of  the  nipple 324 

158B.  Cross  section  of  carcinoma  of  the  nipple 324 

159.  Carcinoma  en  cuirasse 326 

160A.  Desmoid  of  the  pectoral  region 329 

160B.  Desmoid  of  the  pectoral  region 329 

161.  Cancerous  ulcer  following  operation  from  carcinoma  of  the  breast     .     .  331 

162A.  Scar  after  treatment  of  carcinoma  of  the  breast  by  a  plaster     .     .     .  333 
162B.  Cross  section  of  the  preceding  showing  the  large  cancer  nodule  in  the 

center 334 

163A.  Skin  over  a  rapidly  developing  carcinoma.     The  dimpling  of  the  skin 

is  well  marked 336 

163B.  Eecurrent  carcinoma  six  weeks  after  operation 337 

163C.  Slide  from  the  specimen  shown  in  the  preceding  figure 338 

164.  Interstitial    mastitis    with    cysts 341 

165.  Interstitial   mastitis   with   slight   cyst   proliferation 341 

166.  Section    of   interstitial    mastitis 343 

167.  Interstitial    mastitis 344 

168.  Interstitial    mastitis 345 

169.  Interstitial   mastitis   with    deeply    staining   epithelium 345 

170.  Interstitial  breast  with  small  malignant  area 347 

171.  Carcinoma  in  interstitial  mastitis  of  breast 349 

172.  Mixed  tumor  of  the  breast.     (A)   External  surface.      (B)   Cross  section  351 


xiv  ILLUSTRATIONS 

FIG.  P-^'GE 

173.  Slide  of  mixed  tumor  of  the  breast 352 

174.  A  gross  appearance  of  intra canalieulary  tumor  of  the  male     ....  353 

175.  Ei^ithelial   proliferation   of   the   ducts 353 

176.  Mixed  tumor  of  the  breast   (so-called  cystic  sarcoma) 355 

177.  (A)    Connective  tissue  with  spindle-form   nuclei.      (B)    Mixed   cells     .  356 

178.  Encapsulated  carcinoma  of  the  breast 356 

179.  Cyst   in   an  interstitial   mastitis 359 

180.  Cystic  breast 360 

181.  Normal  gland  acini  near  a  cyst 361 

182.  A  cyst  with  smooth  walls,  and  microscopic   section 362 

183.  Mammary  cyst  partly  filled  with  cells 365 

184.  Mammary  cyst  with  papillary  projections  into  the  cyst  cavity     .     .     .  365 

185.  Interstitial  mastitis  with  cyst  formation.     Below  the  larger  cyst  is  a 

malignant  area 367 

186.  Beginning  carcinoma  of  the  breast 368 

187.  Cystic  carcinoma  with  collapsed  walls 369 

188.  Malignant  area  in  the  wall  of  a  cystic  carcinoma 370 

189.  Bursitis  with  apparent  bony  formation  or  calcarious  deposit     ....  373 

190.  Dry  tuberculosis  of  the  shoulder 374 

191.  Infected  lymphatic  glands  of  the  axilla 378 

192.  Abscess  following  tuberculosis   of   a  rib 379 

193.  Lipoma    of    shoulder 381 

194A.  Fracture    of   neck   of    humerus 382 

194B.  Fracture  of  neck  of  humerus.     Eeplaced  and  nailed 383 

195.  Edema  of  the  arm  from  recurrent  carcinoma  of  the  breast     ....  385 

196.  Metastatic  carcinoma  of  the  humerus 386 

197.  Arterio-venous  aneurysm  showing  the  point  of  union  between  the  artery 

and  vein 388 

198.  Mixed-celled  sarcoma  of  the  forearm.     The  x-ray  shows  the  growth  to 

be   free    from   the    bones 391 

199.  X-ray  of  an  osteosarcoma  of  the  forearm  showing  extensive  ossification  392 

200.  Multiple    lipofibrosis    of    the    forearm 394 

201.  Sarcoma    of    the    elbow 395 

202.  Begimiing  melanosarcoma  of  the  arm 396 

203.  Ulcer  of  the  forearm 397 

204A.  Ulcer  of  the  forearm.     The  epithelium  ends  abruptly  with  little  tend- 
ency to  extend  into   the  depth 398 

204B.  Some  plasma-celled  infiltration,  and  but  little  tliickeniug  of  the  vessels  399 

205.  Tuberculosis  of  tendon  sheath 400 

206.  Sporotrichosis   of   arm,    showing   characteristic   lesions 403 

207.  Sporotrichosis,  showing  ulcers  left  after  incision  of  lesions 403 

208.  Hematoma  of  the  wrist 405 

209.  Hygroma  of  the  back  of  the  wrist 407 

210A.  Nonspecific  granuloma  of  the  wrist 408 

210B.  Slide  from  a   nonspecific  granuloma   of  the   wrist 409 


ILLUSTRATIONS  XV 

PIG.  PAGE 

211.  Tuberculosis  of   the  Avrist   joint 411 

212.  LATnpliangioma   of   the   forearm 413 

213.  Periungual  melanoma  of  the  thumb 414 

214.  Melanoma  of  the  thumb 415 

215.  Enehondroma    of   the   index   finger 416 

216.  Enehondroma  of  the  finger 417 

217.  Granuloma  of  the  middle  finger 418 

218A.  Dorsal  surface  of  angioma  of  the  hand 419 

21SB.  Palmar  surface  of  angioma  of  the  hand 420 

219.  Carcinoma  of  the  back  of  the  hand 422 

220.  Dupuvtren's  contraction 423 

221.  Ununited  fracture  of  both  bones  of  the  forearm 425 

222.  Late  result  in  a  case  of  palmer  infection  inadequately  drained     .     .     .  427 

223.  Hydrops  of  the  subgluteal  bursa 431 

224.  Coxa  Vara.     (A)  Shows  direction  of  neck  in  this  ease.     (B)  the  normal  432 

225.  Exostosis  on  articula  head  of  the  femur 434 

226.  Infective  arthritis  of  the  liip  joint 437 

227.  Senile  coxitis 439 

228.  Head  of  femur  from  senile  coxitis 440 

229.  Spontaneous  fracture  of  the  neck  of  the  left  femur     .......  442 

230.  Spontaneous  fracture  of  the  neck  of  the  right  femur 443 

231.  Impacted  fracture  of  the  neck  of  the  femur 445 

232.  Impacted  fracture   of  the  neck  of  the   femur 447 

233.  Sarcoma   of  pubic  bone .  450 

234.  Sarcoma  invohdng  the  pubis,  ischium  and  head  of  the  femur     ....  451 

235.  Carcinoma  developing  in  an  old  burn  scar  of  the  thigh 453 

236.  Melanoblastoma  of   the   thigh 454 

237.  Eecurrent   melanoblastoma   of   the   thigh     ....         456 

238.  Myositis  ossificans  traumatica 458 

239.  Museum  specimen  of  a  bone  from  a  case  of  osteosarcoma 459 

240.  Aneurysm  of  the  femoral  artery 460 

241.  Cross   section   of   the    aneurysm 462 

242.  Multiple  myeloma  of  the  humerus 465 

243.  Malunion  in  fracture  of  the  femur     . 468 

244.  Lateral  displacement  of  fragments 469 

245.  jSTecrotie  bone  removed  from  a  chronic  osteomyelitis 471 

246.  Chronic  osteomyelitis  of  the  femur 473 

247.  Fibroliposarcoma   of  the  popliteal  space 476 

248.  Fibroliposarcoma  of  the  popliteal  space 477 

249.  Myxosarcoma  of  the  sciatic  nerve 479 

250.  Myxosarcoma   of   the   sciatic   nerve 480 

251.  Gummas  of  the  knee 481 

252.  False  aneurysm  of  the  right  popliteal  artery 485 

253A.  Osteosarcoma   of  the   lovrer   end   of   the   femur 488 

253B..  Cross  section  of  osteosarcoma  of  the  knee 489 


Xvi  ILLUSTRATIONS 

FIG.  PAGE 

254.  Bony  deform ity  from  infected  arthritis  of  tlie  knee 491 

255A.  X-ray  of  the  fractured  patella  some  honrs  after  the  injury     ....  494 

255B.  Photograph   of  the  pins  in  position 495 

255C.  The  patellar  fragments  are  shown  in  close  coaptation 406 

256.  Varicose  nicer  of  the   leg 497 

257.  Chronic  ulcer  of  the  leg  following  typhoid  fever  ten  years  ago     .     .     .  499 

258.  Varicose  ulcers  of  the  leg 501 

259.  Marjolin's  ulcer  of  the  leg 504 

260.  Bald-headed  sarcoma  of  the  calf 505 

261.  Sarcoma  of  the  head  of  the   tibia 507 

262A.  Lymphangioma  of  the   calf 509 

262B.  Gross  appearance  of  the  leg 509 

263A.  Appearance  of  the  mass  after  excision 511 

263B.  Cross  section  of  the  excised  mass 511 

264.  Slide  of  lymphangioma  of  the  calf 512 

265.  Tuberculosis    of   the   ankle 513 

266A.  Neurofibroma  of  the  superficial  peroneal  nerve 515 

266B.  Slide  of  the  preceding,  made  up  of  fibrous  tissue  with  some  connective 

tissue    cells .  515 

267.  "Volkmann's  contraction"   of   the   calf   muscles 516 

268.  Diffuse  dry  gangrene  of  the  foot 518 

269.  Localized  dry  gangrene  of  the  foot 520 

270.  Eapidly  developing  dry  gangrene  of  the  foot 522 

271A.  Chondroma   of   the   astragalus 526 

271B.  Cyst  complicating  a   club  foot 528 

271C.  Calcareous  deposit  in  the  wall  of  the  preceding 528 

272.  Bursitis  pcroneus  tendon 529 

273A.  Melanoblastoma  of  the  great  toe 531 

273B.  Slide  of  melanoblastoma  of  the  great  toe 531 

274.  Melanoblastoma    of    the    foot 532 

275.  Spindle-celled  melanoblastoma  of  the  foot 533 

276.  Melanoblastoma  of  the  sole  of  the  foot 535 

277.  Melanoblastoma  of  the  foot.     Alveolar  arrangement  of  spindle  cells     .  536 

278.  Melanoblastoma    of    the    foot 537 

279.  Melanoblastoma  of  the  sole   of  the   foot 5.39 

280.  Melanoblastoma  of  the  sole  of  the  foot 539 

281.  Corn  of  the  sole  of  the  foot 541 

282.  Plantar  corn.     The  epithelial  connective  tissue  junction  shows  no  active 

proliferation 542 

283.  Subungual  exostosis 543 

284.  Kohlcr's  disease 544 


CLINICAL    SURGERY 

BY  CASE  HISTORIES 


VOL.  I. 


CHAPTER  I 

ON  THE  GENERAL  PRINCIPLES  UNDERLYING  THE  STUDY 
OF  SURGICAL  DISEASE 

In  times  past  medical  practitioners  were  wont  to  examine  the  vari- 
ous functions  of  the  body  and  attempt  by  various  means  to  remedy 
the  disorders  of  each  separate  function.  For  instance,  in  tonsillitis 
the  patient  was  given  aconite  for  fever,  calomel  for  constipation, 
and  nitre  for  his  kidneys.  No  attempt  was  made,  in  most  instances, 
to  name  the  disease  or  to  determine  the  etiologic  factors.  After 
bacteriologic  investigation  began  to  bear  fruit  it  was  possible  to 
seek  a  definite  etiology  and  the  physician  could  then  arrive  at  a  spe- 
cific diagnosis  of  disease.  In  tonsillitis,  the  variety  of  bacteria  pres- 
ent was  determined  and  the  fever  allowed  to  take  its  course  under 
the  serene  confidence  that  the  patient  would  recover  spontaneously 
in  a  few  days.  When  the  active  era  of  surgery  began,  the  regional 
diagnosis  of  disease  became  necessary  in  order  that  manual  attack 
might  be  possible.  For  purposes  of  medical  treatment  in  general 
abdominal  inflammations  a  diagnosis  of  peritonitis  was  sufficient, 
but  when  operation  became  in  order,  the  offending  organ  which 
supplied  the  noxious  bacteria  had  to  be  designated. 

Because  of  this  necessity  the  surgeon  has  greatly  advanced  the 
knowledge  of  anatomic  lesions.  However,  he  was  content  with  the 
discovery  of  lesions  he  was  able  to  combat.  He  was  oblivious  to  the 
associated  or  subsidiary  lesions,  and  the  conditions  that  antedated 
the  surgical  disease.  If  the  removal  of  the  lesion  did  not  cure,  an- 
other was  sought.    For  this  reason  various  organs  were  successively 

1 


2  CLINICAL   SriiGERY    BY    CASE    HISTORIES 

removed.  The  ai^peiidix,  the  gall  bladder,  and  in  former  years  the 
ovaries,  were  often  re(iuired  to  do  penance  for  the  most  varied  dis- 
eases. 

Fortunately  the  advance  of  other  branches  of  medical  science 
has  tended  to  disturb  his  composure.  In  order  to  gauge  properly 
the  range  of  safety  of  his  therapeutic  activities  he  has  had  to 
take  cognizance  of  some  of  the  newei-  developments  of  the  physi- 
ologist and  internist.  For  instance,  in  diseases  of  the  endocrine 
system  the  surgeon  must  be  as  well  acquainted  with  the  physiology 
of  the  various  organs,  and  the  pathologic  changes  to  which  they 
are  subject,  as  is  the  internist.  If  he  is  not,  his  untimely  interference 
may  become  embarrassing.  Physiology,  not  anatomy,  becomes  the 
guiding  science.  The  surgeon  can  intuitively  diagnose  the  presence 
of  goiter,  for  instance,  but  intuition  will  not  indicate  the  time  when 
it  is  safe  to  operate.  In  other  cases  he  can  save  himself  much  em- 
barrassment if  he  emulates  the  skill  of  the  internist  in  general  diag- 
nosis. A  patient  may  suffer  from  a  myoma  of  the  uterus,  but  she 
also  may  suffer  impairment  of  renal  function  which  makes  a  sur- 
gical operation  hazardous.  If  there  be  profuse  hemorrhage,  how- 
ever, operation  may  be  demanded  to  combat  the  more  pressing  of 
the  two  diseases. 

It  is  desiral)le  that  the  entire  state  of  the  patient  be  known  before 
the  surgeon  proceeds  with  the  treatment  of  even  the  more  simple 
maladies.  If  a  lesion  is  demonstrable,  the  question  must  be  an- 
swered whether  or  not  the  lesion  is  capable  of  causing  the  symptoms 
complained  of,  in  whole  or  in  part.  If  in  part  only,  it  must  be  de- 
cided if  that  part  is  likely  to  be  relieved  of  which  the  patient  most 
complains.  For  instance,  a  woman  may  complain  of  headache  and 
have  pelvic  lacerations.  If  the  headache  be  migrainous,  operation 
will  not  relieve  her.  No  matter  how  skillfully  the  operation  of  re- 
pair may  be  performed,  the  headache  will  not  be  relieved,  and  in 
her  mind  the  operation  will  have  failed. 

Surgical  problems  may  be  roughly  divided  into  three  categories : 
First,  lesions  entirely  visil)le  to  the  naked  eye  in  which  any  history 
or  (luestioning  is  academic  and  in  which  matters  essential  for  rec- 
ord only  need  be  noted.  ^Fany  tumors  such  as  those  of  the  lip, 
face,  breast,  etc.,  may  be  diagnosed  by  a  single  glance.  A  second 
group  includes  those  which  require  and  admit  of  an  extensive 
studv.      This    includes   most    intrathoracic    and    intraabdominal    dis- 


GENERAL    PRINCIPLES  d 

eases  as  well  as  those  of  the  endocrine  system,  and  all  others  in 
which  a  diagnosis  can  be  arrived  at  only  by  a  study  of  perverted 
physiology.  The  deliberation  permits  and  usually  demands  that 
he  work  together  with  his  internist  colleague,  and  that  both  work 
together  in  the  laboratory  either  in  person  or  by  proxy.  A  third 
group  of  diseases  is  of  such  a  nature  that  time  for  deliberate 
study  is  not  permitted,  and  the  surgeon  must  act  at  once  with 
such  information  as  may  be  available,  depending  more  or  less  upon 
his  intuition  as  to  the  general  problems  involved,  and  upon  his 
judgment  to  guide  him  aright  as  he  proceeds.  This  group  includes 
many  abdominal  disasters,  such  as  perforations  and  gut  obstructions. 
In  such  cases  the  state  of  the  blood  and  of  the  excretory  organs  can 
not  be  allowed  to  weigh  in' the  plan  of  procedure  even  if  their  state 
be  known.  In  fact,  these  factors  are  so  often  perverted  by  the  grave 
disaster  that  their  state  at  one  examination  would  give  evidence  of 
but  little  value. 

The  surgeon,  therefore,  must  have  a  "change  of  pace"  as  the 
baseball  pitchers  say.  He  must  be  deliberate  when  delibera- 
tion is  permitted,  but  he  must  act  with  boldness  and  dispatch 
when  time  is  more  important  than  detailed  knowledge.  The  degree 
in  which  he  has  this  change  of  pace  declares  his  abilities  as  a  sur- 
geon. The  man  who  depends  on  speed  alone  is  dangerous.  The  ha- 
bitual procrastinator  may  allow  the  golden  opportunity  to  pass  by. 
It  can  not  be  too  much  emphasized,  however,  that  the  besetting  sin 
of  the  surgical  profession  is  undue  speed.  This  may  be  due  to  lack 
of  knowledge  which  makes  careful  study  impossible,  or  it  may  be 
due  to  plain  laziness,  he  having  formed  the  habit  of  completing  the 
diagnosis  as  the  operation  proceeds,  or  finally,  it  may  be  due  to 
an  innate  tendency  which  finds  satisfaction  only  in  slashing  and 
the  spattering  of  blood. 

In  the  first  group  of  surgical  problems  the  surgeon  is  vastly  im- 
proved by  experience.  The  eye  learns  to  group  lesions  in  an  instant 
which  formerly  it  could  encompass  only  after  painful  reasoning. 
Even  in  these  cases  careful  consideration  of  each  patient  is  required 
in  order  to  avoid  the  danger  of  falling  into  slothful  habits,  and  to 
catch  up  those  cases  which  are  not  quite  what  they  at  first  seem. 
There  are  always  details  not  at  once  apparent  that  require  record 
for  the  sake  of  science.  These  may  not  be  important  in  the  naming 
of  the  disease  but  may  be  of  vast  importance  in  estimating  the  se- 


4  CMNICAI.    SlKdKKV    KV    CASK    111ST..KU:S 

riousness  of  the  problem  to  the  patient  and  for  the  conduct  of  like 
;:ocXes  in  the  case  of  other  patients.     In  this  gronp  love  o 
Science  only  can  impel  the  surgeon  to  a  complete  study  of  each 
e  r    He  must  he  imbued  with  the  desire  to  achieve  exactness  fo 
:    sa^  c^leience  in  the  hope  that  he  may  extend  the  sum  total 
of  kno.-ledge  as  well  as  perfect  his  own  skill  :n  diagnosis. 

In  the  second  group  exact   diagnosis  is  absolutely  -"--J  f 
he  is  to  be  other  than  a  mere  mechanic  to  act  at  the  dictation  o    h.s 
more  learned  colleagues.    Surgery  of  the  endocrine  ^^ ^^ 
stance,  demands  careful  personal  study.    Surgery  of  the  cianial  and 
thoracic  cavities  demands  the  most  careful  ^^f^^^^^^^JJ^ 
surceon  selects  the  wrong  site  his  efforts  must  fail.    Unfoitunatelj 
for  the  surgeon's  own  good  the  abdominal  cavity  being  one  continu- 
lltZ  d^es  not  recpiire  such  definite  localization;  and  ouce^lmvii^ 
made  his  incision  he  can  often  escape  m  a  measure  the  ^m  of  his 
Tor     It  may  seem  useless  labor  to  make  an  elaborate  examinati  n 
in  order  to  anticipate  only  by  hours  or  days  the  revelations  of  t   e 
oneratino-  room.    However,  such  detailed  consideration  prepares  the 
Xd  of  the  surgeon  for  all  the  possibilities,  and  should  the  unusual 
be  found  at  operation,  he  is  better  fortified  if  he  has  already  foreseen 
it     It  is  the  things  we  have  not  anticipated  that  frighten  us.    There 
is  a  vast  difference  between  an  exploratory  and  a  confirmatory  lap- 

'"'Thrtliird  group  can  be  solved  only  if  the  surgeon  has  a  thorough 
working  knowledge  of  the  less  urgent  diseases.     If  a  pam  is  not  a 
callstone  colic  it  may  be  a  perforation.    It  is  only  by  knowing  the 
Tess  urgent  malady  in  all  its  phases  that  he  quickly  comprehends 
the  more  serious  one.     The  vast  majority  of  ill-advised  operations, 
which  end  disastrously,  are  due  to  mistaking  lesions  of  minor  impor- 
tance for  grave  ones.    Many  a  woman  with  menstrual  pain  has  been 
operated  upon  under  the  diagnosis  of     extrauterine  pregnancy,  or 
acute  appendicitis.     Or  grave  lesions  are  operated  on  at  inoppor- 
tune times,  as  hemorrhages  from  gastric  ulcer.     There  are  really 
verv  few  real  emergencies  in  surgery.    If  two  questions  can  be  an- 
swered in  the  negative--ls  there  perforation!"   and   "Is   there 
hemorrhage r '-the  surgeon  will  do  well  to  think  carefully  before 

he  acts.  ,      ^ 

Senn  pictured  the  ideal  surgeon  as  one  who  knows  as  much  ot 

diseases  as  the  internist  and  has  in   addition   the  technical  skill 


GENERAL   PRINCIPLES  5 

Avhich  belongs  to  surgery.  That  is  to  say,  lie  slioulcl  be  a  physician 
who  can  operate.  The  late  Joseph  Eastman  was  wont  to  say  that 
no  one  should  attempt  to  practice  gynecology  who  is  not  himself 
a  good  neurologist.  He  must,  indeed,  often  carefully  ponder  how 
much  of  the  picture  is  due  to  the  manifestation  of  impaired  nervous 
balance  and  how  much  to  objective  disease.  It  is  only  by  properly 
evaluating  the  various  factors  that  he  can  hope  to  determine  before- 
hand how  much  improvement  will  follow  the  correction  of  obvious 
anatomic  impairment.  He  must  even  go  further  and  properly  esti- 
mate the  social  relations  of  the  patient,  for  an  unfavorable  environ- 
ment may  be  the  determining  element.  The  surgeon  should  utilize 
the  internist  and  other  trained  specialists  to  the  highest  degree  as 
factors  in  his  education,  but  should  depend  on  them  as  little  as 
possible  in  a  specific  case.  The  more  he  can  do  this,  the  better  is  he 
fortified  against  the  multitude  of  complications  that  constantly  con- 
front the  surgeon  at  the  operating  table.  It  is  such  considerations 
as  these  that  make  the  broadest  possible  education  of  paramount 
importance  to  the  surgeon. 

Responsibility  rests  much  more  heavily  upon  the  surgeon  than 
upon  the  internist.  His  acts  are  for  better  or  for  worse  and  he 
must  be  able  to  determine  beforehand  which  it  will  be.  The  in- 
ternist has  the  consolation  of  knowing  that  if  his  therapeutic  endeav- 
ors do  no  good  they  will  do  no  considerable  harm.  Most  of  the 
disasters  that  confront  the  surgeon  are  of  his  own  making.  With 
all  the  advances  of  our  science  none  can  live  up  to  the  ideal  it  pre- 
sents.    The  surgeon's  own  limitations  are  his  only  handicap. 

These  considerations  make  it  imperative  that  the  surgeon  estab- 
lish a  routine  of  procedure  which  must  be  followed,  in  so  far  as  it  is 
possible,  in  each  case.  So  important  is  this  that  many  hospitals, 
in  the  protection  of  their  own  good  name,  demand  that  the  surgeon 
produce  a  careful  history  and  a  working  diagnosis  before  they  ex- 
tend to  him  the  privileges  of  their  operating  room  service.  It  is 
very  satisfactory  to  notice  that  this  outside  stimulus,  to  whip  the 
laggards,  comes  from  within  the  surgical  profession  itself.  The 
American  College  of  Surgeons,  in  order  to  aid  surgeons  in  perfect- 
ing their  records,  has  attempted  to  present  a  model  by  which  the 
surgeon  may  be  guided.  The  chief  importance  that  can  be  attached 
to  this  endeavor  is  the  fact  that  this  body  recognizes  the  importance 
of  the  utmost  care  in  forming  an  opinion.     In  so  far  as  their  con- 


6  CLINICAL   SURGERY    BY    CASE    HISTORIES 

Crete  plan  goes  it  must  be  declared  far  from  ideal;  and  at  best  can 
but  serve  as  a  point  of  departure  from  which  each  surgeon  may  work 
out  his  own  more  complete  plan. 

The  essential  thing  is  that  there  should  be  some  routine.  The  pre- 
cise nature  of  it  is  relatively  less  important.  It  must  be  one  that 
can  be  cari-ied  out  in  all  cases.  There  is  a  difference  between  com- 
pleteness and  verl)osity,  however,  which  must  be  clearly  appreciated. 
The  beginner  must  be  more  prolix  than  the  expert,  for  in  his  inex- 
perience he  must  include  much  that  is  irrelevant  lest  he  overlook 
something  of  importance.  Simplicity  is  the  handmaid  of  efficiency. 
An  artist  with  a  few  skillful  strokes  expresses  an  attitude  of 
thought,  while  those  laciving  artistic  skill  produce  but  an  expression- 
less object  after  the  most  laborious  application  of  strokes  and  colors. 
So  the  expert  clinician  in  a  few  short  sentences  maj^  record  exactly 
the  history  of  the  disease. 

There  is  a  minimum,  however,  that  can  not  be  reduced.  Every 
scheme  should  include  the  following  headings:  (1)  History.  (2) 
Examination,  including  laboratory  findings.  (3)  Diagnosis.  (4) 
Treatment.     (5)  Pathology.     (6)  Aftercourse. 

By  following  such  a  scheme,  clinical  study  becomes  the  determi- 
nation of  the  physical  state  of  the  individual  and  not  merely  the 
naming  of  this  chief  complaint.  The  subdivisions  above  enumer- 
ated must  all  be  taken  together.  Diagnosis  becomes  only  an  es- 
timate of  present  state,  and  treatment  but  an  attempt  to  influ- 
ence temporarily  the  course  of  events.  If  we  view  it  so  the  im- 
portance of  the  element  of  subsequent  course  becomes  at  once  ap- 
parent. Unless  this  is  determined,  the  diagnosis  and  treatment  are 
often  but  speculation  and  fall  short  of  their  greatest  good  because 
the  influence  is  but  temporary. 

HISTORY 

The  history  must  give  account  of  the  essential  happenings  in  the 
patient's  life  up  to  the  point  where  the  surgeon's  observation  begins. 
Wide  latitude  may  be  allowed  in  the  taking  of  the  history.  It  may 
be  very  simple  if  the  surgeon  wishes  to  limit  his  interests  to  the 
needs  of  the  patient  with  regard  to  the  particular  ailment,  or  it  may 
be  of  any  degree  of  detail  which  particular  scientific  requirements 
may  demand.  In  general,  however,  records  should  have  a  broader  pur- 
pose than  the  benefit  of  the  individual.     They  should  regard  matters 


GENERAL    PRIXCEPLES  7 

of  general  benefit.  Furthermore,  a  history  complete  for  today  may  be 
incomplete  for  tomorrow,  when  we  have  learned  to  look  at  the  af- 
fection from  a  wider  angle.  A  history  should,  therefore,  be  com- 
plete at  least  in  all  diseases,  the  whole  scope  of  which  we  do  not  fully 
comprehend.  Albert  states  that  when  a  man  falls  from  a  house  and 
breaks  a  leg,  the  state  of  the  grandfather's  health  is  not  important. 
Yet  one  must  remember  that  there  are  instances  in  which  both  family 
and  past  history  is  of  importance  in  cases  of  fracture.  Therefore, 
while  one  must  not  insist  that  every  case  be  represented  by  a  cer- 
tain number  of  ^^I'itten  pages,  at  the  same  time  there  is  no  disease 
so  simi)le  but  that  elaborate  inquiry  may  not  at  times  be  of  impor- 
tance. It  is  such  considerations  as  these  that  make  a  wide  knowl- 
edge so  important  in  the  taking  of  a  history.  AVhile  this  task  is  usu- 
ally relegated  to  the  interne  as  assistant,  it  is  in  many  instances  the 
most  important  of  the  procedures. 

As  a  matter  of  convenience,  the  history  is  divided  into  several 
heads.  There  is  the  account  of  the  antecedents  of  the  patient  as 
an  individual — the  family  history.  This  is  the  first  in  chronologic 
order,  but  it  is  usually  of  least  importance.  Then  there  follows 
the  account  of  diseases  and  accidents  he  has  already  had  to  contend 
with  prior  to  his  present  atfection — that  is  to  say,  his  past  history. 
Finally  there  is  the  account  of  the  condition  that  brings  the  patient 
and  surgeon  together — the  present  disease. 

While  the  order  in  which  the  various  phases  chronologically  fol- 
low is  as  above  enumerated,  it  is  much  more  subservient  to  efficiency 
to  reverse  the  order;  that  is,  present  complaint,  past  diseases,  family 
history.  It  is  only  after  one  has  some  notion  as  to  the  present  ail- 
ment, that  the  other  two  phases  can  be  intelligently  followed.  If 
the  chronologic  order  is  followed,  family  and  personal  history  are 
apt  to  be  put  down  in  the  most  perfunctory  manner.  One  has  but 
to  look  over  the  average  interne's  chart  to  convince  himself  that 
this  is  so.  C4eneral  statements  abound  in  them  which  remind  one 
of  the  familiar  court  room  platitude,  "incompetent,  irrelevant  and 
immaterial  and  tending  to  call  for  the  conclusions  of  the  witness." 
For  instance,  we  find  that  the  father  died  of  inflammation  of  the 
bowels  or  of  lung  trou])le.  If  this  information  is  germane  to  the 
case  in  hand  further  information  should  be  sought  which  may  per- 
mit the  examiner  to  form  a  conclusion  of  his  own  as  to  the  nature 
of  the  disease  which  caused  the  demise  of  the  ancestor.     One  can 


8  CLINICAL    SIRGERY   BY    CASE    HISTORIES 

uot  follow  out  all  these  clues  in  all  eases,  else  a  history  would  be 
drawn  out  into  endless  confusion.  The  same  applies  to  the  personal 
history.  Perhaps  the  patient  states  that  he  had  typhoid  fever. 
Questioning  may  indicate  that  it  was  an  attack  of  appendicitis.  One 
would  not  care  to  follow  out  this  detail  if  the  patient  had  a  frac- 
tured thigh,  but  if  the  present  complaint  involves  the  question  of 
some  obscure  abdominal  comjjlaint.  such  detailed  information  might 
be  of  use.  Since  to  be  of  any  use  history  of  past  conditions  must 
contain  definite  information,  it  is  best,  therefore,  not  to  consider 
the  past  history  until  a  presumptive  diagnosis  of  the  present  ailment 
has  been  made.  Then  those  factors  in  past  history,  both  family  and 
personal,  which  may  have  a  bearing  on  the  present  complaint  may 
be  followed  out  as  far  as  possible.  The  facts  regarding  the  past 
affection  sbould  in  that  case  be  as  carefully  catalogued  as  though 
the  ailment  were  now  present. 

HISTORY  OF  THE  PRESENT  DISEASE 

The  preferable  course,  therefore,  is  to  begin  at  once  to  enter  into 
the  matter  that  brings  the  patient.  He  is  primed  for  his  present 
complaints  and  has  no  interest  in  past  family  or  personal  afflictions. 
If  we  begin  with  the  present  ailment,  what  then  shall  be  the  first 
question  to  be  put  when  we  confront  the  patient  ?  It  is  well  to  be  as 
brief  in  the  social  amenities  as  possible.  If  the  patient  becomes  im- 
pressed at  once  that  the  surgeon  has  the  single  matter  in  mind  of 
determining  his  ailment  he  is  less  apt  to  be  discursive.  A  fool- 
proof initial  question  has  not  yet  been  devised.  There  seems  to  be 
no  plan  that  will  prevent  the  question  being  parried.  If  one  asks 
the  direct  question,  "AVhat  brings  you  here?"  ''To  find  out  what 
is  the  matter  with  me"  is  likely  to  be  the  answer.  If  one  asks. 
"What  is  the  chief  complaint?"  he  may  be  told  that  it  is  catarrh  of 
the  stomach  or  some  such  reply  which  gives  the  conclusion  of  the 
patient  or  of  his  physician.  Possibly  the  question  most  likely  to 
elicit  a  reply  that  will  serve  as  a  basis  for  further  questions  is. 
"How  long  have  you  been  sick?"  A  few  will  make  evasive  replies 
such  as  "a  long  time."  or  "always."  These  replies  are  valuable 
in  a  way,  for  they  give  a  clue  to  the  character  of  the  patient.  If 
one  gets  such  a  reply,  he  is  safe  in  marking  down  then  and  there, 
"prognosis  bad"  for  they  are  all  descendants  of  the  old  lady,  who, 
when  interrogated  by  her  pastor  regarding  the  state  of  her  health. 


GENERAL    PRINCIPLES  9 

replied,  "Poorly,  thank  God,  poorly."  Throughout  the  preliminaries 
the  examiner  must  be  alert  in  order  to  determine  the  sort  of  pa- 
tient with  whom  he  has  to  deal.  It  will  be  of  vast  importance  after 
the  real  complaints  are  once  reached. 

Throughout  the  history  the  nature  of  the  reply  often  gives  a  clue 
to  the  real  nature  of  the  complaint.  After  the  time  of  beginning 
of  the  complaint  has  been  fixed  by  the  patient,  it  is  often  of  im- 
portance to  inquire  especially  in  order  to  determine  whether  that 
is  actually  the  beginning  of  the  trouble.  On  examination  the  sur- 
geon may  discover  the  time  given  by  the  patient  can  not  be  correct, 
and  in  reply  to  a  pointed  question,  the  patient  is  apt  to  express  the 
opinion  that  the  supposed  previous  illness  was  some  irrelevant  dis- 
ease which  had  nothing  to  do  with  the  present  trouble.  For  instance, 
one  may  be  told  that  the  patient  has  been  suffering  from  obstruction 
in  the  rectum  for  three  weeks.  If  the  examiner  finds  a  constricting 
carcinoma  of  evident  longer  standing,  the  patient  may  admit  on 
further  cjuestioning  that  he  has  suffered  from  piles  for  a  year. 

Each  symptom  should  be  recorded  in  the  words  of  the  patient  if 
possible.  The  understanding  of  the  meaning  of  words  differs  among 
different  individuals.  Certain  persons  habitually  employ  the  super- 
lative degree  in  their  descriptions.  An  ''awful  pain"  may  mean 
a  slight  colic  or  it  may  mean  a  perforated  ulcer.  The  difference 
is  expressed  in  the  manner  of  speaking,  and  the  actual  words  used  may 
have  to  be  qualified  by  a  record  of  the  surgeon's  impressions. 

As  a  matter  of  fact,  of  all  symptoms,  pain  is  the  most  imj)ortant ; 
and  it  is  described  with  greater  variability  than  any  other  symptom. 
One  must  determine  its  intensity.  If  a  patient  has  really  had  se- 
vere pain  he  is  very  likely  to  lead  off  with  this  fact.  If,  on  the  other 
hand,  the  patient  comes  to  the  point  of  pain  after  touching  discur- 
sively on  other  things,  one  may  be  sure  that  there  has  been  little 
real  pain  no  matter  what  the  qualifying  adjective  employed  may  be. 
Usually  if  the  pain  has  been  severe,  patients  at  once  suggest  the 
character  of  it.  A  gallstone  colic,  a  renal  crisis  or  a  perforating 
ulcer  is  at  once  described  with  the  necessary  superlative  adjectives. 
In  the  minor  degrees  only  of  pain  is  it  necessary  to  follow  with 
other  questions  in  order  to  determine  the  character.  Did  the  pain 
radiate  or  stay  in  the  same  spot?  was  it  an  ache?  a  sharp  lan- 
cinating or  cutting  pain?  or  was  it  a  cramp?  Such  questions  may 
elicit  other  information. 


10  C'LINICAI.    SURGERY    BY    CASE    HISTORIES 

The  site  of  pain  also  must  be  actually  determined.  The  patient's 
words  must  he  recorded.  His  ideas  of  topographic  anatomy  may  not 
agree  with  ours,  and  an  agreement  on  this  matter  between  doctor 
and  patient  must  be  reached  before  a  proper  understanding  may  be 
had.  There  is  nothing  more  exasperating  than  to  read  in  the  his- 
tory that  the  patient  has  pain  in  the  epigastrium,  and  when  one 
goes  to  the  patient  one  finds  the  patient  said  stomach,  meaning 
thereby  the  lower  abdomen,  the  recorder  having  taken  on  himself 
the  liberty  of  substituting  the  more  professional  term.  My  earliest 
lesson  in  this  wide  divergence  in  the  meaning  of  terms  was  ob- 
tained while  listening  to  the  discourses  of  a  portly  Methodist  elder. 
He  would  rub  the  overhanging  cliff  of  his  more  than  generous 
paunch,  exiiatiating  on  how  his  heart  went  out  for  small  boys  who 
persisted  in  fishing  on  Sunday.  I  was  familiar  with  Steele's  phj'si- 
ology,  and  I  leanunl  then  and  there  that  even  the  inspired  may 
mistake  the  pains  of  incipient  starvation  for  a  yearning  for  the 
safety  of  small  boys. 

It  is  important  for  many  reasons  to  use  the  patient's  terms.  If 
he  says  he  has  pain  in  the  stomach  and  he  indicates  the  lower  ab- 
domen, put  it  down  so.  It  gives  an  index  of  the  man's  intelligence. 
If  he  says  pit  of  the  stomach,  say  so,  and  if  he  says  epigastrium  put 
that  down.  It  is  expression  of  character  of  pain  one  is  after  at  this 
stage  and  not  the  exact  location.  Location  is  properly  a  task  of 
physical  examination. 

Other  symptoms  must  be  studied  with  equal  care,  such  as  bloating, 
headache,  and  dizziness.  One  need  not  have  a  lawyer  to  aid  him 
in  finding  out  whether  the  patient  Avho  complains  of  headache  is  a 
victim  of  migraine.  In  such  cases  when  the  subject  of  headache  is 
broached  he  proceeds  without  further  urging  to  parade  his  vocabu- 
lary of  superlative  adjectives.  The  same  is  true  of  syphilitic  and 
pressure  headaches.  If  the  patient  is  indefinite  as  to  the  character 
and  frecjuency  of  headache,  it  obviously  is  not  a  matter  of  paramount 
importance. 

It  is  the  purpose  of  a  history  to  determine  whether  a  symptom 
must  be  evaluated  on  the  statement  of  the  patient  or  whether  phys- 
ical examination  is  likely  to  elicit  additional  evidence.  For  instance, 
if  a  patient  complains  of  headache  one  should  find  out  from  the 
history,  if  possible,  whether  it  is  toxic,  functional  or  due  to  sinus 
trouble.     If  one  gets  the  impression  that  there  is  an  organic  basis 


GENERAL    PRINCIPLES  11 

he  will  search  the  nose  closely,  or  will  follow  up  the  possibility  of 
syphilis  even  if  the  Wassermann  reaction  is  negative.  If  it  is 
frontal  and  is  preceded  by  photophobia  or  muscle  volitantes  one 
will  have  little  hope  of  finding  an  organic  basis  and  will  proceed 
with  every  care  to  establish  the  diagnosis  by  history  alone.  History 
must  furnish  some  clue,  let  it  be  repeated,  of  the  nature  of  the  dis- 
ease in  order  that  the  examiner  may  be  direct,  specific  and  persis- 
tent in  his  questions.  If  it  fails  to  do  so  it  must  be  gone  over  again 
and  again.  Often  the  most  careful  search  is  required  to  furnish  the 
clue.  Every  effort  should  be  made  to  find  a  guide  for  further  exam- 
ination. Routine  examinations  are  valuable,  no  doubt,  but  if  per- 
functorily done,  become  mere  travesty  on  exact  clinical  method. 
There  is  small  chance,  for  instance,  to  find  tubercle  bacilli  in  the 
urine  in  the  routine  examination  when  made  by  a  laboratory  attend- 
ant who  has  no  idea  of  the  importance  of  the  examination.  It 
is  only  when  one  suspects  renal  tuberculosis  that  he  is  likely  to  find 
acid-fast  bacilli  in  the  urine. 

The  beginner  sometimes  allows  the  facts  of  the  history  to  influence 
his  physical  findings.  For  instance,  if  the  history  points  to  a  possi- 
ble appendicitis,  he  may  be  more  apt  to  find  a  muscular  rigidity, 
whether  it  is  present  or  not.  This  tendency  can  not  be  considered 
as  a  valid  objection  against  the  preliminary  consideration  of  the 
history.  If  the  examiner  has  not  the  power  of  concentration  or  the 
ability  to  suspend  judgment  until  the  facts  are  all  collected  he 
lacks  the  first  requirements  of  a  good  diagnostician. 

HISTORY  OF  PAST  DISEASES 

Fine  maneuvering  is  needed  to  make  this  of  value.  I  once  heard 
an  interne  glibly  read  from  his  chart  "Patient  had  measles,  chicken 
pox,  scarlet  fever,  gonorrhea,  and  other  diseases  of  childhood."  One 
often  reads  "patient  had  typhoid  fever,  pneumonia,  and  malaria," 
without  qualifying  information.  If  the  history  of  the  present  com- 
plaint makes  it  important  to  determine  whether  he  had  a  disease  in- 
dicated in  the  history,  such  statements  must  be  amplified  by  more 
detailed  information.  If  he  had  typhoid,  how  long  was  he  in  bed! 
What  were  the  symptoms  in  the  beginning?  What  were  the  dura- 
tion and  disturbances  of  convalescence?  In  following  such  detail 
one  must  be  sure  that  the  patient  understands  the  meaning  of  the 
questions  asked  him.     If  the  patient  had  an  irrelevant  disease,  such 


12  CLINICAL    SLKGERY    BY    CA^E    HISTORIES 

as  a  broken  leg,  then  the  past  history  is  of  little  importance  (since 
the  passage  of  the  eighteenth  amendment).  If  he  has  a  varicocele 
on  the  right  side,  the  determination  of  past  urinary  disturbance  is 
of  the  greatest  importance,  but  if  it  is  on  the  left  side,  one  may 
be  pardoned  if  one  omits  such  details. 

There  can  be  no  unvarying  method  of  seeking  history.  If  one 
suspects  syphilis  one  may  proceed  tactfully  by  inquiring  whether  the 
patient  has  ever  had  a  rash,  whether  the  hair  has  ever  fallen  out, 
and  the  like.  Or  one  may  pointedly  inquire  whether  he  ever  had 
syphilis;  or  if  the  clinical  evidence  is  strong,  and  one  wants  to  be 
bombastic,  one  may  inquire  ivhen  he  had  it.  Usually  patients  appre- 
ciate tact  in  such  cases.  If  one  speaks  of  a  spade  as  an  agricultural 
implement  the  euphemism  often  relieves  the  patient  of  embarrass- 
ment. The  question  of  abortions  requires  tact ;  whether  they  were 
spontaneous  or  induced  requires  still  more.  Often  history  is  de- 
liberately falsified.  It  is  not  uncommon  to  find  a  patient  who  de- 
nies pregnancy,  yet  one  finds  that  she  has  a  bilateral  laceration. 
Is  this  due  to  childbirth  or  to  the  too  brisk  use  of  the  dilator?  The 
condition  of  the  perineum  may  indicate  the  truth. 

The  purpose  of  investigating  the  past  history  is  to  throw  light 
on  the  disease,  that  is,  to  secure  confirmatory  evidence  and  not  to 
satisfy  curiosity.  One  should  constantly  keep  this  fact  before  the 
patient's  mind.  He  will  be  much  more  apt  to  make  an  effort  to  pre- 
sent accurate  and  complete  replies. 

The  requirements  of  science  must  not  be  overlooked.  In  cases  in 
which  there  is  obviously  gall  bladder  trouble,  it  is  a  matter  of  in- 
terest to  know  whether  there  has  been  an  antecedent  typhoid  fever 
or  appendiceal  attack.  If  from  the  account  of  the  disease  a  diag- 
nosis is  evident,  the  history  of  past  diseases  has  for  its  chief  pur- 
pose the  discovery  of  an  antecedent  which  may  have  an  etiologic 
relationship. 

FAMILY  HISTORY 

The  account  of  the  faniih'  antecedents  usually  occupies  the  top 
of  the  history  sheet.  It  rarely  gives  information  of  value,  except 
that  it  indicates  in  a  general  Avay  the  fecundity  of  the  family.  The 
account  usually  reads  something  like  this :  "Father  died  of  stomach 
trouble ;  mother  living  and  well ;  four  brothers  living  and  well.  One 
died  in  infancy.     Three  sisters  living  and  well;  one  died  of  malaria 


GENERAL   PRINCIPLES  13 

at  tlie  age  of  fifteen."  Nothing  is  more  calculated  to  irritate  than 
the  tautological  expression  ''living  and  well." 

Rarely  does  a  family  history  aid  in  the  diagnosis  of  a  surgical 
lesion,  yet  one  must  not  pass  it  as  wholly  useless.  A  history  of 
tuberculosis  may  put  us  on  guard  but  the  appearance  of  the  patient 
usually  is  a  more  potent  warning.  A  few  diseases  have  a  familial 
relationship  and  while  the  family  history  may  not  be  of  importance 
in  the  diagnosis,  information  of  interest  to  eugenics  may  be  elicited. 

If  family  history  is  to  be  of  any  use  at  all,  names  of  diseases  should 
never  be  accepted  at  par.  Each  disease  in  the  ancestor  must  be 
searched  as  carefully  as  if  it  were  a  past  disease  of  the  patient. 
It  is  because  such  information  is  seldom  forthcoming  that  the  family 
history-  even  with  the  exercise  of  the  greatest  care  is  of  so  little 
value.  It  must  be  insisted  again  and  again  that  the  name  of  a  dis- 
ease standing  alone  means  nothing,  whether  it  refers  to  past  or  pres- 
ent diseases  of  the  patient  before  us,  or  to  those  of  his  ancestors. 
To  say  the  patient  has  cancer  means  little ;  to  say  he  had  cancer 
means  less ;  to  say  an  ancestor  had  cancer  means  nothing  at  all  unless 
the  statement  is  amplified  by  details  that  make  an  adequate  com- 
prehension possible.  The  investigation  of  each  disease  responsible 
for  an  ancestor's  demise  should  be  followed  out  as  carefully  as  if 
we  stood  beside  the  bed  of  the  departed  person  and  were  responsible 
for  the  rendition  of  a  proper  diagnosis.  It  is  only  by  going  into 
each  factor  carefully  that  the  family  history  can  be  made  of  use. 
As  usually  written  it  is  worse  than  useless. 

EXAMINATION 

The  objective  signs  of  disease  are  perceived  by  unaided  senses 
of  touch,  sight  or  hearing,  or  by  means  of  some  method  or  instru- 
ment of  precision.  The  former  we  designate  as  physical  examination 
pure  and  simple,  while  the  latter  we  may  regard  as  laboratory  ex- 
amination. Laboratory  aids  range  from  tests  for  albumin  to  serum 
reactions. 

PHYSICAL  EXAMINATIONS 

The  evidence  obtained  by  our  own  investigations  may  be  divided 
into  the  routine  and  the  specific.  After  we  have  the  history  we  have 
an  idea  as  to  where  we  may  find  the  trouble.  Examination  of  organs 
probably  not  involved  is  then  properly  defined  as  routine.    Routine 


14  CLIXICAL   SURGERY   BY    CASE    HISTORIES 

examinations,  so  far  as  they  go,  must  be  reliable,  thongli  tliej'  need 
not  be  so  complete  as  if  some  disease  of  the  organ  examined  were 
anticipated.  Pupillary  reactions,  muscular  coordination  and  re- 
flexes should  always  be  recorded  by  a  trustworthy  examiner.  It 
will  save  one  from  cutting  down  on  the  stomach  of  a  tabetic  at  some 
time.  The  condition  of  the  nose,  the  mouth,  and  particularly  the 
teeth  and  tonsils,  may  be  noted.  The  state  of  the  heart  and  lungs, 
likewise,  must  be  recorded.  Examination  of  the  urine,  blood,  and 
now  frequently  the  Wassermann  reaction,  are  regarded  as  routine. 
Because  they  are  routine,  these  matters  too  often  are  left  wholly 
to  inadequately  trained  assistants.  This  is  particularly  true  of  the 
examination  of  the  urine  and  the  ^Yassermann  test.  Koutine  exam- 
inations rarel}'  detect  more  than  the  grosser  lesions.  A  careful  his- 
tory will  as  a  rule  find  more  accessory  lesions  than  will  the  routine 
examination.  For  this  reason  divided  examinations  lose  much  of 
their  value.  The  one  who  writes  the  history  gains  more  impressions 
than  he  can  possibly  commit  to  paper.  When  the  patient  is  passed 
along  to  someone  else  for  further  examination,  unless  that  examiner 
has  carefully  studied  the  history,  he  is  apt  to  overlook  the  imj^ortant 
points  for  investigation.  The  otherwise  commendable  "group"  ex- 
amination loses  its  value  unless  very  closely  coordinated.  After  all 
the  evidence  is  obtained  it  requires  the  analysis  of  a  man  of  broad 
knowledge  to  use  the  various  bits  of  evidence  to  advantage.  If  care 
is  not  exercised  the  value  of  a  group  examination  will  not  rise  above 
the  capacity  of  the  weakest  member  of  the  group. 

The  examiner  of  the  main  problem  supplies  the  most  important 
element  in  the  diagnosis.  If  a  good  history  does  not  point  to  a  lo- 
calized lesion  there  likely  isn't  any.  However,  it  must  be  sought 
for  assiduously  just  the  same.  In  using  the  history  as  a  guide  to  the 
place  to  search  one  must  have  care  lest  one  be  prejudiced  by  such 
information.  Many  an  innocent  appendix  has  been  removed  be- 
cause the  patient  said  he  had  sensitiveness  below  the  Mason  and 
Dixon  line.  The  diagnosis  may  depend  on  whether  the  tenderness  is 
deep  or  superficial,  and  if  the  latter,  whether  it  is  ephemeral  or 
permanent.  Superficial  tenderness  due  to  visceral  disease  can  be 
read  in  the  expression  of  the  patient's  face.  Often  irrelevant  de- 
tails give  aid  in  the  interpretation  of  findings.  Rouge  and  wrinkles 
equal  the  given  age  plus  ten.  So  rouge,  plus  abdominal  pain  usually 
mean  superficial  pain.    In  walking  the  corridors  if  one  sees  powder 


GENERAL    PRIXCIPLES  15 

rag  or  pipe  on  the  bedside  table  one  may  safely  leave  the  patient 
to  the  care  of  the  interne.  The  snrgeon  must  constantly  keep 
in  mind  that  he  has  first  of  all  to  deal  ^vith  a  personality  which  may 
emphasize  or  obscure  vital  things. 

One  must  not  take  accessory  or  neurotic  complaints  for  more 
than  they  are  worth.  It  seems  sometimes  as  though  neurotics  never 
die.  But  even  vith  these  we  should  have  faith  in  the  general  law 
of  the  perishability  of  all  organic  matter  and  hold  our  minds  open 
to  the  possible  coexistence  of  an  organic  disease.  In  fact  in  per- 
sons of  labile  nervous  system  the  finer  organic  lesions  may  have  a 
double  importance  and  these  should  be  sought  for  with  redoubled 
sympathy  and  care. 

After  the  discursive  inventory  has  been  made,  a  careful  examina- 
tion of  the  organ  likely  to  be  the  seat  of  the  disease  as  determined 
by  the  history,  must  be  made.  It  is  well  to  do  this  before  the  patient 
has  been  tired  and  irritated  by  probably  irrelevant  examinations. 
If  examinations  likely  to  test  the  modesty  of  the  patient  are  required 
it  is  often  well  to  defer  these  until  the  last.  Those  examinations 
which  involve  functional  tests  require  a  visit  to  the  laboratory  and 
may  properly  be  postponed  to  the  last  or  be  consigned  to  some  one 
particularly  skilled  in  such  work. 

If  the  physical  findings  and  the  history  do  not  correspond,  the 
Avhole  problem  must  be  gone  over  again.  Xo  diagnosis  is  safe  unless 
all  the  various  phases  are  in  harmony.  Most  errors  come  from  diag- 
nosing conditions  that  never  exist.  A  predilection  for  diagnosing 
rare  affections  indicates  immaturity.  In  irremovable  doubt  as  to 
the  nature  of  the  disease  the  wise  man  has  an  eye  out  for  the  law  of 
probability.  The  gnawing  feeling  that  impels  the  politician,  ac- 
cording to  his  statement,  to  activity  in  behalf  of  his  fellow-man, 
experience  teaches,  is  more  apt  to  be  due  to  an  instinct  of  self-preser- 
vation. So,  also,  a  lesion  of  the  ileocecal  region  is  more  likely 
to  be  a  pus  microbal  infection  than  an  actinomycotic  one.  AVe  learn 
from  experience  that  the  one  is  common  while  the  other  is  rare.  We 
anticipate  the  one  and  maintain  a  receptive  but  skeptical  attitude 
toward  the  other. 

Generally  speaking,  the  methods  common  to  physical  diagnosis 
in  general  as  employed  by  the  internist  are  employed  by  the  surgeon. 
That  is  to  say,  inspection,  palpation,  auscultation  and  percussion. 
The  various  maneuvers  receive   a   difPerent  value,   however.     Wliile 


16  ILIXICAL    SUKGEKY    BY    CASE    IIISTOKIES 

the  iuternist  employs  largely  auscultation  and  percussion,  the  sur- 
geon relies  chiefly  on  inspection  and  palpation.  This  is  readily 
understood  Avhen  one  remembers  that  usually  there  is  some  local- 
ized lesion  in  sui'gical  diseases.  Before  he  can  remove  it,  it  must 
i)i  his  mind's  eye  have  length,  breadth  and  thickness.  Therefore, 
he  endeavors  to  establish  boundaries  by  means  of  sight  and  touch. 

Too  often,  however,  surgeons  are  prone  to  begin  too  soon  to  apply 
the  hands.  Inspection  often  reveals  much  which  can  be  learned 
by  comparing  the  supposedly  affected  region  with  the  supposedly 
normal.  Often  differences  in  contour  not  at  first  apparent  become 
so  after  careful  observation.  The  general  topography  should  first 
be  carefully  noted.  Often  anatomic  landmarks  are  discernil)le  to 
the  eye  and  any  deviation  becomes  at  once  apparent.  Such  points 
are  particularly  likely  to  be  found  where  the  skin  is  in  close  rela- 
tion to  the  more  deeply  lying  parts. 

It  is  only  after  all  the  evidence  available  by  inspection  has 
been  obtained  that  the  sense  of  touch  should  be  invoked.  Touch 
verifies  the  location  of  landmarks  and  in  this  way  defines  the  ana- 
tomic limits  of  the  disease.  Once  this  is  done  the  actual  field 
of  disease  must  be  more  closely  investigated. 

The  examiner  first  takes  cognizance  of  the  relation  of  the  dis- 
eased area  to  known  fixed  points.  If  it  is  unattached,  its  relation 
to  more  movable  structures,  such  as  fascia  and  skin,  are  determined. 

After  these  factors  have  been  noted  then  the  physical  characters 
of  the  lesion  itself  are  observed.  The  nature  of  the  surface  and  the 
consistency  of  the  lesion  are  the  chief  matters  of  record.  If  lesions 
are  not  directly  visible  or  palpable,  the  nature  of  the  disease  must 
be  determined  by  inference.  In  such  instances  the  reaction  of  the 
disease  on  surrounding  structures  must  be  taken  into  account.  Does 
it  influence  the  general  economy?  Instruments  of  precision  and 
the  laboratory  often  play  a  prominent  role  but  often  the  sensitive- 
ness and  the  secondary  reactions,  such  as  rigidity,  must  be  taken 
into  account.  Percussion  and  auscultation  often  must  be  invoked  in 
order  to  determine  the  extent  of  change  in  the  surrounding  tissues. 

In  conducting  the  physical  examination  the  surgeon  should  seek 
as  much  independence  from  the  statements  of  the  patient  as  possible. 
Having  obtained  a  history  of  pain  in  a  given  region  he  should  seek 
to  elicit  pain  by  manipulation  unaided  by  question  as  to  whether 
the  manipulation  causes  pain  or  not.     To  ask  the  patient  whether 


GENERAL   PRINCIPLES  17 

a  given  area  is  sensitive  to  the  pressure  he  is  making,  after  having 
been  told  by  the  patient  that  the  area  is  sensitive,  is  to  cause  the 
patient  to  give  an  affirmative  answer.  If  pain  is  caused  by  the 
manipulation  the  patient  will  make  it  known  by  sign  or  sound.  Ex- 
pression of  pain  during  examination  must  be  carefully  evaluated, 
however.  Loud  lamentations  without  the  usual  physical  signs  of 
pain  should  be  accepted  with  caution.  Repetition  of  the  manipula- 
tion may  fail  to  elicit  the  alleged  pain.  The  neurotic  is  willing  to 
exclaim  a  iew  times  but  this  grows  monotonous  and  manipulations 
once  complained  of,  later  are  accepted  without  comment,  particu- 
larly if  the  patient  at  that  time  is  allowed  to  talk  about  a  new 
symptom. 

THE  LABORATORY  EXAMINATIONS 

The  relation  of  the  surgeon  to  the  diagnostic  laboratory  is  va- 
riously interpreted.  One  must  make  up  his  mind  to  one  of  two  at- 
titudes— either  he  must  take  what  is  told  him  or  he  must  see  for 
himself.  If  the  laboratory  man  could  always  comply  with  the  bibli- 
cal injunction  and  reply  "yea,  yea"  or  "nay,  nay"  the  management 
of  a  case  in  cibsentia  from  the  laboratory  would  be  feasible  and  op- 
erable. Unfortunately  answers  are  not  always  to  be  made  without 
equivocation,  and  unless  we  are  familiar  with  the  difficulties  the 
laboratory  man  contends  with,  we  can  not  properly  evaluate  his 
reports. 

Those  not  familiar  with  the  limits  and  difficulties  of  the  labora- 
tory worker  are  apt  to  overestimate  the  value  of  the  labora- 
tory report.  No  one  should  listen  to  the  laboratory  man  until  he 
has  made  the  clinical  investigation  and  has  arrived  at  a  tentative 
diagnosis.  After  this  has  been  done  the  laboratory  findings  can 
be  fitted  into  their  proper  place  and  given  their  right  value.  If 
the  laboratory  report  is  considered  before  this  is  done,  one  may  pro- 
ceed on  wholly  erroneous  lines.  The  laboratory  findings  may  be 
positive  for  some  minor  pathologic  condition,  and  may  lead  the 
surgeon  from  the  cause  of  the  chief  complaint.  This  minor  condi- 
tion may  be  fundamental  and  directly  related  or  it  may  be  independ- 
ent of  the  disease  and  not  concern  the  patient  in  so  far  as  the  re- 
lief of  the  chief  complaint  is  concerned.  This  tendency  to  overes- 
timate the  value  of  the  laboratory  report  is  emphasized  by  the  com- 
mon attitude  toward  the  Wassermann  reaction.    No  matter  what  the 


18  CLIXICAL    SURGERY   BY    CASE   HISTORIES 

clinical  findings  may  be  the  report  from  the  laborator}-  is  allowed 
to  dictate  the  treatment.  The  "Wassermanii  reaction  is  never  infal- 
lible. Many  clinical  signs  of  syphilis  are  infallible.  AVhen  the 
clinical  signs  are  positive  the  AVassermann  reaction  is  interesting 
but  not  important.  It  is  altogether  common  to  meet  patients  "who 
have  cancer  and  who  because  they  presented  a  positive  Wassermann 
reaction  have  been  vigorously  subjected  to  intensive  antisyphilitic 
treatment  while  the  malignant  disease  progressed  unhindered.  In 
doubtful  cases  the  AVassermann  reaction  may  present  the  first  clue 
of  the  nature  of  the  disease.  It  is  only  in  those  cases  where  the  his- 
tory and  physical  findings  fail  to  give  any  clue  to  the  nature  of 
the  disease  that  the  laboratory  should  be  looked  to  for  the  first  hint 
as  to  the  correct  diagnosis. 

If  the  laboratory  is  to  be  of  the  greatest  use  there  must  be  close 
contact  between  the  surgeon  and  the  laboratory  worker.  In  order 
that  the  laboratory  work  be  sufficiently  intensive,  some  idea  of  the 
direction  it  should  take  should  be  had  from  the  clinical  examination. 
It  is  not  possible  to  carry  out  in  full  detail  all  the  possible  laboratory 
tests  in  all  cases.  In  an  obscure  kidney  lesion  for  instance,  the 
routine  examination  of  the  urine  is  not  sufficient.  In  a  supposed 
tuberculosis  the  technician  must  have  some  encouragement  lest  he 
desist  in  his  search  for  bacilli  before  sufficient  trial  has  been  made. 
The  surgeon  should  know  that  the  examination  for  tubercle  bacilli 
is  difficult  and  that  one  or  two  negative  slides  are  of  little  value.  A 
negative  examination  at  one  time  may  be  replaced  by  a  positive  one 
at  a  later  date.  The  surgeon  must  know  how  persistent  he  must  be 
in  the  search  for  evidence.  The  same  persistence  and  care  at  times 
is  required  in  every  disease  that  has  a  distinctly  known  etiologic 
factor  and  no  matter  how  positive  the  clinical  findings,  we  can  not 
rest  until  the  laboratory  has  produced  the  confirmatory  findings.  If 
the  surgeon  demands  needless  detail  from  the  laboratory  he  will 
soon  lose  the  respect  of  the  pathologist  and  when  careful  detail 
work  is  really  needed  his  requests  will  go  unheeded.  I  once  had  an 
obstetrician  bring  in  a  placenta  that  had  lain  in  formalin  solution 
six  months  and  ask  that  a  culture  for  tubercle  bacilli  be  made. 
Many  surgeons  are  wholly  unaware  how  ridiculous  their  requests 
sometimes  appear  to  the  laboratory  worker.  It  is  only  by  making  in- 
telligent demands  that  intelligent  cooperation  can  be  expected. 
"Wholly  reprehensil)le  is  the  disposition  of  some  surgeons  to  demand 


GENERAL    PRINCIPLES  19 

all  sorts  of  needless  examinations  in  order  to  impress  the  patient 
with  his  thoroughness.  They  may  or  may  not  accomplish  this  purpose, 
but  most  certainly  merit  and  receive  the  contempt  of  the  laboratory 
man.  Too  often  the  laboratory  man  is  regarded  by  the  surgeon  as  a 
sort  of  servant  who  does  laboratory  work  because  he  can  not  prac- 
tice surgery.  As  a  matter  of  fact  the  laboratory  man  more  often 
turns  to  laboratory  work  because  it  represents  the  most  exact  phase 
of  the  subject  and  he  chooses  his  field  because  the  slipshod  work 
of  the  average  surgeon  is  repellent  to  him. 

If  the  surgeon  does  not  himself  choose  to  acquire  laboratory  skill, 
he  must  at  least  learn  so  much  of  it  that  he  can  converse  with  and 
understand  the  qualifying  phrases  the  laboratory  man  must  employ. 
In  addition  he  must  appreciate  that  when  he  is  in  the  laboratory  he 
is  in  the  presence  of  a  man  who  is  his  superior  in  knowledge  in  so 
far  at  least  as  it  pertains  to  the  matter  in  hand.  So  approached  the 
laboratory  can  render  a  service  more  equivocal  perhaps,  but  cer- 
tainly more  reliable  than  is  usually  rendered. 

Close  contact  with  laboratory  affairs  is  essential  for  another  rea- 
son. The  pathologist,  be  he  ever  so  skillful,  can  only  diagnosticate 
what  the  surgeon  presents  for  his  consideration.  The  importance 
of  this  is  often  seen  in  so-called  diagnostic  section.  If  the  surgeon 
does  not  know  malignant  tissue  when  he  sees  it,  how  shall  he  know 
what  to  cut  for  the  pathologist  to  examine?  And  if  he  knoAvs  malig- 
nant tissue  when  he  sees  it,  why  bother  about  the  pathologist?  He 
may  as  well  go  on  and  complete  the  operation.  The  pathologist 
might  be  invited  to  do  the  operation.  He  could  tell  more  by  finger- 
ing the  whole  tissue  than  by  a  hurried  slide  examination.  The  sec- 
tion may  lead  to  wrong  conclusions  because  proper  tissue  was  not 
examined  and  the  pathologist  may  be  blamed  for  the  error.  In 
fact,  it  seems  that  the  chief  purpose  of  inviting  the  pathologist  is 
to  have  some  one  to  receive  the  blame  in  case  of  error.  Some 
pathologists  in  doubtful  cases  diagnosticate  malignancy  in  order 
to  protect  themselves,  rather  than  demand  more  evidence.  If  be- 
nign a  radical  operation  will  cure  ;  if  malignant  the  operation  should 
be  done,  they  argue.  The  attitude  of  both  pathologist  and  surgeon 
is  attested  by  the  advice  of  some  surgeons  to  do  the  radical  opera- 
tion in  all  cases  of  doubt.  Many  women  have  needlessly  lost  their 
breasts  because  of  this  travesty  on  science.    There  are  also  not  lack- 


20  CLINICAL    SURGERY    BY    CASE    HISTORIES 

ing-  surgeons  who  demand  of  their  pathologists  diagnoses  that  will 
harmonize  with  their  clinical  conclusions.  Others  again  expect  diag- 
noses that  will  permit  them  to  perform  a  contemplated  operation.  I 
have  more  than  once  been  berated  by  a  surgeon  for  returning  a  diag- 
nosis of  nonmalignancy  in  a  clipping  from  the  cervix  in  cases  in  which 
he  desired  to  do  a  radical  operation. 

There  is  one  situation  when  such  cooperation  is  of  value.  A  good 
pathologist  can  bolster  up  a  poor  surgeon.  If  the  opinion  of  the 
pathologist  is  needed,  he  should  be  taken  in  full  confidence.  He 
then  not  only  sees  the  slide,  but  hears  something  of  the  history 
and  perchance  sees  the  area  from  which  the  tissue  was  cut  and  pos- 
sibly the  area  from  which  the  tissue  was  not  cut.  The  pathologist 
must  be  regarded  as  a  coAvorker  and  not  as  a  servant  or  underling, 
and  should  be  accorded  all  the  courtesies  of  any  other  consultant. 
It  is  only  by  acquainting  him  with  all  the  facts  that  he  is  able  to 
render  the  best  service,  rienerally  speaking,  the  pathologist  must 
first  diagnosticate  the  doctor  before  he  proceeds  to  diagnosticate 
the  patient's  disease.  It  is  only  by  following  this  sequence  that  he 
can  know  how  much  importance  to  place  on  the  observation  of  tlie 
attendant. 

The  microscope  is  an  instrument  of  precision,  the  proper  use  of 
which  for  aii}'  purpose  requires  time.  It  can  educate  the  surgeon, 
but  it  can  not  supply  in  a  moment  the  information  it  could  transmit 
to  him  at  leisure.  In  order  that  the  surgeon  may  comprehend 
the  scope  of  usefulness  and  the  limitations  of  the  laboratory  he 
must  make  himself  a  part  of  it  just  the  same  as  he  educates  his 
sense  of  touch  in  palpation.  The  palpating  finger  in  fact  can  not 
reach  its  maximum  of  sensitiveness  unless  the  comprehension  is 
sensitized  b.v  contact  with  the  microscopic  pictures  of  like  lesions. 
It  would  be  far  more  rational  for  the  pathologist  to  take  charge  of 
the  surgical  wards  and  employ  an  artizan  to  do  the  operating  than 
for  a  surgeon  to  attempt  to  practice  surgery  without  a  compre- 
hension of  the  scope  of  usefulness  and  limitations  of  the  laboratory, 
A  technician  may  be  trained  in  a  few  years;  a  lifetime  is  insufficient 
to  equip  a  laboratory  worker  to  the  maximum.  The  young  man 
can  not  do  better  than  to  heed  the  advice  of  the  late  Dr.  Christian 
Fenger,  "If  you  want  to  learn  surgery  you  must  beat  a  path  be- 
tween the  operating  room  and  the  laboratory." 


GENERAL    PRIXCIPLES  21 

THE  DIAGNOSIS 

When  the  evidence  obtained  from  the  history  and  physical  ex- 
amination lias  been  assimilated  the  real  task  of  diagnosis  begins. 
True,  in  order  to  take  a  proper  history  one  must  have  an  eye  to 
possibilities,  and  to  make  a  proper  physical  examination  he  mnst 
have  an  eye  to  probabilities,  yet  one  should  not  allo^v  himself  to 
formulate  working  conclusions  until  all  evidence  from  both  these 
sources  has  been  weighed.  AVhen  the  presumptive  diagnosis  has 
been  arrived  at.  then  the  laboratory  report  must  be  considered.  It 
may  confirm  or  negate  the  preliminary  conclusion.  It  may  indicate 
that  the  clinical  conclusion  may  be  correct  as  to  the  chief  com- 
plaint but  wrong  as  to  the  chief  menace  to  the  patient.  For  instance, 
clinical  examinations  may  correctly  determine  an  enlarged  prostate 
but  the  laboratory  examination  may  reveal  an  impending  uremia 
or  a  pyelonephritis.  Should  one  consider  first  the  laboratory  find- 
ings, he  might  fix  his  eye  on  the  kidney  lesion  and  fail  to  search 
for  the  causative  enlargement  of  the  prostate.  A  most  common 
cause  of  error  is  that  of  ignoring  minor  discrepancies  in  the  evi- 
dence. The  main  picture  may  indicate  a  certain  disease  while  one 
point  refuses  to  harmonize.  For  instance,  a  patient  who  had 
a  history  indicating  a  gastric  ulcer  was  seen  to  limp  when  he  walked. 
He  ascribed  this  to  pain  in  the  hip.  He  had  a  retrocecal  appendi- 
citis, the  removal  of  which  relieved  his  stomach  trouble.  A  patient 
may  suffer  from  uterine  hemorrhage  and  the  presence  of  a  uterine 
myoma  may  be  easily  recognized.  But  the  real  cause  of  hemorrhage 
may  be  a  primary  pernicious  anemia  and  the  presence  of  the  myoma 
be  wholly  incidental.  The  location  of  the  tumor  and  the  blood  pic- 
ture must  be  the  guide. 

Only  experience  and  a  training  in  the  logic  of  diagnosis  can  indi- 
cate to  the  surgeon  the  degree  of  positiveness  with  which  the  diag- 
nosis may  be  stated.  Even  with  the  most  unequivocal  evidence  one 
should  remember  that  diagnoses  never  exceed  the  superlative  de- 
gree of  probability.  If  this  attitude  is  maintained  one  leaves  his 
mind  open  for  the  reception  of  new  facts. 

Generally  speaking,  error  in  diagnosis  is  not  due  to  a  lack  of 
evidence  but  to  improper  conclusions  based  on  the  evidence.  This 
is  often  due  to  a  preconceived  impression  rather  than  to  a  lack  of 
knowledge.  If  one  is  not  on  the  alert  the  conclusions  of  a  fellow- 
practitioner  are  apt  to  influence  the  diagnosis.     Sometimes  the  op- 


22  CLIXICAI.   SIRGERY    BY    CASE    HISTORIES 

posite  is  true;  one  instinctively  disputes  the  findings  of  a  rival. 
There  is  but  one  safeguard;  have  no  friend  but  truth,  no  enemy  but 
error. 

A  large  experience  in  associations  which  force  an  orderly  habit 
of  thought  is  the  best  guarantee  of  accurate  conclusions.  The  large- 
ness of  the  experience,  however,  is  dependent  on  the  clarity  of  vision 
rather  than  the  number  of  cases  he  has  seen.  I  once  did  six  autopsies 
within  a  few  Aveeks  for  a  surgeon  who  explored  six  bellies  for  gen- 
eralized carcinosis.  He  called  all  of  them  tuberculosis  and  learned 
nothing  from  any  of  them.  I  learned  more  from  the  first  one  than 
he  did  from  all  six.  Large  statistics  overawe  the  uninitiated  but 
do  not  necessarily  broaden  the  mind  of  the  observer.  The  tapping 
of  a  drum  produces  sound,  but  it  never  rivals  the  peal  of  thunder. 
It  is  a  question  of  intensity  not  repetition.  A  clarified  vision  alone 
advances  the  precision  of  our  logic. 

Once  the  surgeon  has  diagnosed  the  disease  he  must  diagnose  his 
patient.  If  such  and  such  a  diagnosis  is  made,  then  the  problem 
comes  to  determine  the  risk.  Risk  of  life  fi'om  the  operation  must 
be  less  than  the  risk  from  the  disease.  The  personal  equation  must 
enter  here.  This  personal  equation  is  made  up  of  the  sum  of  ac- 
C[uired  skill  and  honest  introspection.  The  first  we  obtain  by  toil, 
the  second  the  gods  give  us — or  deny  us.  The  proposed  operation 
must  be  capable  of  influencing  the  symptoms  of  which  the  patient 
desires  to  be  rid.  The  repair  of  the  cervix  will  not  cure  a  migraine, 
neither  will  the  remoAal  of  the  appendix  transform  a  petulant  child. 
There  are  conditions  simulating  these  that  may  be  relieved  by  re- 
moving such  causes.  Too  little  regard  for  the  niceties  of  diagnosis 
has  led  to  much  unnecessary  operating.  The  modern  problem  of  the 
person  Avho  "suffered  much  from  many  physicians"  is  too  often  the 
product  of  operating  for  nonmalignant  conditions. 

The  proper  diagnosis  of  the  chief  and  subsidiary  lesions  often  in- 
dicates lines  along  which  we  may  reduce  some  of  the  latter  before 
attacking  the  main  lesion.  A  myoma  may  produce  a  grave  secondary 
anemia.  The  treatment  of  the  secondary  condition  may  make  the 
prognosis  of  the  primary  lesion  better.  AVe  need  constantly  to  sup- 
plement our  technical  skill  by  extra  precautions.  "We  get  the  pa- 
tient into  the  best  possible  condition.  We  lessen  the  risk  by  await- 
ing the  proper  time,  by  using  the  least  injurious  anesthetic,  by 
selecting   the   proper   environment,   perchance   the   division   of   the 


GENERAL   PRINCIPLES  23 

operation  into  several  stages.  All  of  these  things  imply  the  most 
minute  diagnosis,  not  only  of  the  patient's  major  disease  but  also 
of  the  minor  ones.  All  these  factors,  while  they  do  not  pertain  to 
the  naming  of  the  disease,  do  contribute  enormously  to  the  success 
and  safety  of  the  operation. 

The  diagnosis  is  never  complete  until  all  the  evidence  is  assem- 
bled for  the  formulation  of  the  prognosis.  This  must  encompass 
the  risk  of  life  and  the  probabilities  of  a  relief  from  his  symptoms. 
The  patient  wants  not  only  to  live,  but  to  be  well.  This  applies  also 
to  the  operations  that  are  defacing.  The  prognosis  must  be  made 
up  from  a  knowledge  of  the  state  of  the  patient  and  the  abstract 
knowledge  of  the  disease  in  general.  Other  diseases  which  may 
afflict  the  patient  also  must  be  taken  into  account  in  the  final  sum- 
mary. 

TREATMENT 

With  the  completion  of  the  diagnosis  the  site  and  length  of  the 
incision  is  determined.  In  deciding  the  direction  of  his  incision 
the  surgeon  must  consider  the  rules  of  operative  technic,  but  it  is 
often  better  to  disregard  these  rules  than  to  operate  under  unneces- 
sary difficulties  while  observing  them.  The  proper  length  of  an  in- 
cision is  one  which  permits  one  to  work  skillfully  and  expeditiously. 
Not  infrequently  surgeons  lengthen  the  incision  from  time  to  time 
during  the  operation.  This  is  a  sign  of  incomplete  diagnosis  even 
after  the  incision  has  been  made.  Once  this  is  made  the  surgeon 
must  seek  the  lesion  and  determine  its  relation  to  his  preconceived 
notion  of  how  it  would  look.  If  the  diagnosis  encompasses  the  le- 
sion, the  matter  becomes  one  of  manual  dexterity  only;  if,  however, 
lesions  more  or  less  extensive  than  foreseen  are  found,  a  rapid  read- 
justment is  in  order.  If  no  lesion  is  found,  other  areas  capable 
of  giving  rise  to  such  symptoms  must  be  sought  out.  If  the  lesion 
is  capable  of  explaining  only  a  part  of  the  symptoms,  further  search 
is  in  order.  If  the  diagnosis  and  findings  coincide,  further  search 
is  not  warranted.  IMore  than  the  necessary  handling  of  tissue  is 
detrimental  to  the  patient. 

In  operating  on  malignant  diseases  or  suspicious  lesions  it  is  often 
necessary  during  the  course  of  the  operation  to  incise  the  tissue. 
The  feel  as  the  tissue  divides  under  the  knife  and  the  appearance  of 
the  cut  surface  become  a  part  of  the  diagnostic  procedure.  The  sur- 
geon pauses  in  his  treatment,  in  fact,  in  order  to  supplement  the  evi- 


24  CLINICAL   SURGERY    BY    CASE    HISTORIES 

dence  for  diaguosis.  A  simple  or  a  radical  operation  may  be  indicated, 
depending  on  whether  the  tis"ue  is  found  to  be  benign  or  malignant. 

In  carrying  out  the  technic  he  must  first  see  with  the  eye  of  the 
pathologist  the  extent  the  operation  must  take.  This  determined, 
he  must  see  with  the  eye  of  the  anatomist  the  best  way  of  accom- 
plishing its  removal.  If  the  disease  is  an  extensive  one  the  require- 
ments of  the  pathology  may  be  greater  than  the  anatomic  poisibili- 
ties;  that  is,  the  removal  of  tissues  necessary  to  life  may  be  indi- 
cated by  the  extent  of  the  disease.  An  operation  may  be  theoreti- 
cally and  technically  feasible  from  both  the  pathologic  and  the 
anatomic  point  of  view,  and  yet  the  results,  as  proved  by  experience, 
may  be  such  that  the  additional  burden  produced  by  the  operation 
is  not  warranted.  ^lany  late  malignancies,  such  as  carcinomas  of 
the  uterus  and  stomach,  often  fall  into  this  category.  In  such  cases 
the  surgeon  should  not  hesitate  to  abandon  the  attempt. 

The  style  of  operating  is  more  or  less  in  the  hands  of  the  opera- 
tor. Some  operate  rapidly,  one  might  say  uproariously.  I  once 
heard  a  Scotchman  say  that  the  real  test  of  a  gentleman  is  whether 
or  not  he  remains  such  when  he  is  drunk;  so  the  test  of  the  sur- 
geon is  the  mental  poise  he  displays  when  serious  difficulties  arise. 
If  he  can  not  control  his  temper,  he  can  not  control  any  other  of 
the  mental  processes.  A  display  of  temper  at  the  operating  table  is 
an  infallible  sign  of  mental  obfuseation.  A  steady  hand  must  have 
to  guide  it  a  clear,  calm  mind. 

The  object  to  be  secured  in  an  operation  is  to  relieve  the  patient 
of  his  disease  with  the  least  injury  to  himself.  Injury  is  inflicted 
rapidly  or  slowly.  A  gentle  though  slow  operator  may  employ  more 
time  yet  injure  his  patient  less  than  the  rapid  operator.  A  deft  op- 
erator may  combine  both  speed  and  gentleness.  ]\Iost  operators 
consume  time  not  because  of  manual  but  because  of  mental  clumsi- 
ness. Thought  waves  travel  rapidly  if  they  have  a  familiar  road  to 
travel  and  a  well-tried  landing  place.  AVhen  they  travel  slowly. 
it  is  because  of  an  unfamiliar  road  and  untried  terminals. 

Operations  are  long  because  of  the  uncertainty  the  surgeon  feels 
as  to  how  he  should  go.  Murphy  truly  said,  '"The  tyro  may  know 
when  to  get  in  but  only  the  expert  knows  when  to  get  out."'  This 
uncertainty  is  due  frequently  to  a  lack  of  a  clear  comprehension  of 
the  pathologic  state  and  less  often  to  technical  difficulties  of  the 
operation. 


GENERAL   PRINCIPLES  25 

PATHOLOGIC  FINDINGS 

The  study  of  the  tissue  in  the  laboratory  has  a  dual  purpose;  to 
rectify  and  extend  the  diagnosis  and  to  complete  and  expand  his 
education.  The  primary  purpose  of  the  clinical  laboratory  is  to  di- 
agnose the  case  at  hand.  The  primary  purpose  of  the  pathologic 
laboratory  is  to  extend  the  range  of  information  of  the  surgeon 
and  of  science  in  general.  Usually  both  these  ends  are  best  served 
m  the  completion  of  the  records.  Close  contact  with  this  phase 
can  not  be  too  often  urged.  It  is  said  mother  can  attend  church 
for  the  whole  family.  This  maj'  be  true,  but  certainly  no  surgeon 
can  attain  scientific  salvation  by  having  a  proxy  do  i^enance  in  the 
laboratory. 

It  is  certain  that  surgeons  who  know  full  well  that  a  diagnosis 
Avhich  states  that  the  patient  had  appendicitis  indicates  but  little, 
are  often  perfectly  satisfied  with  a  report  from  the  laboratory  that 
a  tumor  is  "cancer."  There  are  many  more  kinds  of  cancer  than 
there  are  appendicitides.  Unless  the  surgeon  familiarize  himself 
with  the  tissues  first  hand,  he  must  remain  ignorant  of  the  finer 
distinctions.  In  a  diagnostic  study  the  laboratory  worker  can  add 
much  by  a  simple  laboratory  report,  but  the  study  of  the  tissue  he 
has  removed  can  best  be  done  b}'  the  surgeon  himself.  If  he  is  to 
recognize  like  tissue  at  a  subsequent  meeting,  he  must  know  its 
minute  structures.  The  chief  value  of  the  study. of  the  slide  con- 
sists in  the  fact  that  the  more  we  familiarize  ourselves  with  it  the 
more  we  are  independent  of  it.  It  is  only  by  the  constant  working 
with  the  gross  tissues  and  comparing  them  with  the  slides  made  from 
them,  with  our  own  or  other  hands,  that  we  become  able  to  view 
the  gross  with  the  microscopic  eye. 

A  good  pathologist  is  able  to  "call"  an  ever  increasing  percent- 
age of  the  tissues  he  sees  in  the  gross,  but  never  all.  The  most  skill- 
ful meets  his  surprises.  The  great  pistol  shot.  Captain  Lee,  says 
the  fascination  in  shooting  is  in  the  fact  that  "you  can't  get 
them  all  in  the  10  ring."  The  fascination  in  the  study  of  tissue 
is  in  the  fact  that  there  are  always  surprises  of  various  kinds  and 
degrees.  Properly  viewed,  the  laboratory  appeals  to  the  instinct 
of  the  sportsman,  and  once  he  has  learned  the  joy  of  it,  he  turns  as 
instinctively  to  it  for  recreation.  The  sporting  instinct  is  aroused 
because  there  are  tissues  no  one  can  diagnose. 


26  CLINICAL   SURGERY    BY    CASE    HISTORIES 

The  findings  of  the  pathoh)gic  laboratory  must  be  constantly  com- 
pared with  the  clinical  complex  that  produced  them.  And  who  but 
the  surgeon  shall  form  the  connecting  link?  Neither  does  his  trou- 
ble end  when  he  has  faithfully  studied  his  tissues  in  gross  and  in  the 
slide.  They  must  be  always  available  along  with  the  history  sheet 
when  demanded  for  comparison  with  like  or  similar  cases.  What 
was  observed  in  his  youth  may  become  clear  when  experience  has 
supplied  similar  eases.  As  vision  groAvs,  slides  Avill  need  relabeling 
just  as  old  clinical  charts  require  revision,  if  their  author  be  pro- 
gressive. 

Because  of  the  perishal)ility  of  tissue,  it  is  desirable  that  when- 
ever feasible  they  be  photographed.  This  has  the  double  purpose 
of  preserving  the  record  for  him.self  and  also  of  making  it  available 
for  those  who  shall  come  after  him.  Often  looking  over  an  old  pic- 
ture will  contribute  as  much  to  our  education  as  the  examination  of 
a  new  ease.  At  the  first  look  the  eye  may  not  get  all  details  but 
the  camera  is  impartial  and  unprejudiced.  Those  more  expert  will 
read  more  from  the  picture  than  from  our  description,  and  what  is 
more  important,  do  it  with  vastly  greater  speed.  There  is  no  greater 
evidence  of  honesty  than  the  presentation  of  pictures,  gross  and  mi- 
croscopic, along  with  the  case  histories.  The  study  of  pathologic 
tissue  is  but  the  completion  of  the  diagnosis.  AYithout  it  the  clini- 
cal determination  must  often  be  problematic  and  incomplete  and  it 
is  as  vital  to  the  final  completion  of  the  record  as  any  other  proce- 
dure. 

AFTER-COURSE 

After  all  this  has  been  done  the  surgeon  feels  he  has  finished  his 
study.  He  may  rightly  feel  that  he  has  done  his  work  faithfvilly 
and  well;  how  well  time  alone  can  tell.  He  may  record  the  his- 
tory with  ever  so  much  care,  make  his  examination  with  every  at- 
tention to  detail,  reason  with  the  skill  of  a  master  logician,  study 
carefully  the  lesion  at  operation,  and  finally  study  carefully  the 
tissue  in  the  laboratory,  but  the  real  trial  is  yet  to  come.  The  patient 
has  the  final  word.  If  the  patient  is  not  recovered,  all  our  fine 
reasoning  is  of  no  avail.  If  he  is  not  well,  we  must  find  out  why. 
If  we  diagnosticate  a  tumor  as  benign.  Avhat  does  it  avail  if  the 
patient  dies  of  recurrence  ?  In  order  to  finally  determine  the  cor- 
rectness or  falsity  of  our  diagnosis,  we  must  know  the  ultimate  state 
of  the  patient. 


GENERAL    PRINCIPLES  27 

Inquiry  after  operation  must  follow  several  channels.  The  imme- 
diate oiJerative  recovery  and  complications,  if  any,  must  all  he 
noted.  This  phase  of  the  problem  is  the  most  precise  of  all.  It 
can  be  recorded  in  positive  terms.  Too  often  if  operative  recovery 
is  satisfactory  no  further  eifort  to  amplify  the  record  is  made.  The 
operative  recovery  testifies  only  to  the  surgeon's  skill  in  the  art  of 
surgery.  The  greater  test  of  skill  in  the  science  of  surgery  is  yet 
to  come. 

The  real  problem  is  whether  or  not  the  patient  has  been  relieved 
of  Avhat  he  complained.  If  he  is  not  relieved,  then  the  surgeon  has 
failed  in  the  eyes  of  the  patient  and  must  begin  his  inA'estigations 
anew.  Possibly  the  diagnosis  was  wrong.  AYe  may  have  removed 
the  appendix  when  the  patient  had  a  renal  stone.  Perhaps  the  dis- 
ease was  not  the  only  one  from  which  he  suffered.  Perhaps  he  is 
suffering  from  a  new  disease  acc[uired  after  we  applied  treatment 
to  a  previous  one.  The  patient  may  ascribe  these  symptoms  to  the 
disease  for  which  we  treated  him.  Perhaps  the  patient  has  been 
relieved  and  feigns  symptoms  for  reasons  of  his  own. 

All  these  factors  must  be  closely  checked  up  for  our  own  pro- 
tection and  still  more  for  our  own  education,  for  it  is  only  when 
we  know  our  errors  that  we  can  hope  to  correct  them.  There  is 
no  stimulus  to  exact  diagnosis  equal  to  a  study  of  after  results.  Re- 
sults that  are  wholly  satisfactory  are  jDcrhaps  in  the  minority.  Care- 
ful study  will  often  disclose  something  that  we  would  like  changed. 
It  is  only  by  painfully  considering  them  that  we  can  engender  the 
desire  to  avoid  their  repetition  in  the  future.  The  greatest  stimulus 
to  effort  is  humiliation ;  and  the  creator  of  humiliation  is  the  realiza- 
tion of  our  shortcomings,  and  the  trumpet  of  our  shortcomings  is  the 
voice  of  the  after-course. 


CHAPTER  II 

DISEASES  OF  THE  CRANIU:\[  AND  CONTEXTS 

The  diseases  of  the  head,  exclusive  of  the  face,  are  conveniently 
divided,  for  diagnostic  purjaoses,  into  those  of  the  enveloping  cra- 
nium, and  the  contained  l3rain.  Xot  infrequently  the  one  may  in- 
volve the  other  and  sometimes  it  may  be  difficult  to  determine 
Avhich  is  chiefly  affected.  Therefore,  the  disease  of  both  must  always 
be  kept  in  mind  even  "when  one  alone  seems  to  be  at  fault. 

DISEASES  OF  THE  CRANIUM 

The  majority  of  the  diseases  and  injuries  of  the  scalp  are  of  a 
minor  nature  and  belong  to  the  earliest  chapter  in  the  young  sur- 
geon's experience.  The  removal  of  wens  and  the  closure  of  scalp 
wounds  are  the  first  tasks  assigned  to  the  junior  interne.  There 
are  a  few  diseases  that  belong  to  the  mature  surgeon,  and  some 
that  transcend  anj-  surgical  attack — such  as  metastatic  tumors  and 
the  like.  In  determining  these  problems  a  broad  general  knowledge 
is  necessary"  in  order  to  properly  interpret  them.  One  must  always 
keep  in  mind  what  relation  a  cranial  disease  may  bear  to  the  more 
important  organ  beneath. 

CASE  1. — An  infant  three  months  old  was  brought  because  of  a 
tumor  above  its  ear. 

History. — It  was  noticed  when  the  baby  was  two  weeks  old  that 
there  ^vas  a  red  spot  above  its  left  ear.  This  soon  began  to  enlarge, 
and  became  elevated  above  the  surface.  It  gradually  increased  in 
size  until  the  past  two  weeks  when  the  increase  has  been  more 
rapid.     Otherwise  the  child  seems  normal. 

Examination. — ^An  area  2  cm.  in  diameter  and  8  to  9  mm.  high  is 
located  above  the  left  ear.  It  is  bluish  red  in  color  being  mottled 
with  these  colors  in  some  regions.  It  is  partly  compressible,  but 
when  completely  compressed,  there  is  still  some  su])stance  of  the 
tumor  palpable. 

28 


DISEASES    OF    THE    CRANIUM    AND    CONTENTS 


29 


Diagnosis. — The  lesion  is  obviouslj'  a  cavernous  hemangioma.  The 
diagnostic  problem  consists  in  determining  its  tendency.  The  his- 
tory indicates  that  it  is  developing  more  rapidly  than  the  child. 
The  palpatory  findings  bear  this  out.  A  pure  eavernoma  should 
completely  disappear  on  pressure;  the  fact  that  it  does  not  indicates 
some  inter-cavernous  proliferation.  In  such  cases  the  destruction 
of  the  lesion  should  be  attempted.  In  the  more  rapidly  growing 
type,  the  line  of  demarcation  between  normal  skin  and  the  angioma 
is  more  clearly  marked  than  in  the  stationarj^  ones  (Fig.  1). 

Treatment. — Loops  of  catgut  were  passed  through  the  healthy 
skin  so  as  to  include  the  subcutaneous  tissue  beneath.    After  a  ring 


Fi.a 


1. — Angioma   of   the   temple   region   showing   the    sharp   line    of    demarcation   between    the 
skin  and  the  top   of  the  tumor. 


of  these  was  formed  about  the  mass  the  ether  mask  was  removed  and 
a  wet  towel  placed  over  the  baby's  face.  An  electric  cautery  point 
was  then  thrust  into  the  tumor,  and  the  growth  was  thoroughly 
destroyed.  The  central  portion  of  the  growth  was  obtained  for  ex- 
amination. 

Pat]io''ogy. — The  tissue  is  made  up  of  large  vessels  with  fairly 
thick  cellular  walls  (Fig.  2).  In  the  tissue  between  the  vessels  are 
many  large  cells  with  large  ovoid  nuclei.  These  are  evidently  de- 
veloping cells. 

After-course. — The  defect  left  from  the  cauterization  rapidly 
granulated  in  and  was  soon  obliterated. 


30 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


Comment. — When  these  congenital  angiomas  do  not  develop  ex- 
cept to  keep  pace  with  the  development  of  the  child  they  may  be 
ignored.  Occasionally  they  disappear  spontaneonsly.  When  they 
shoAV  active  development  they  should  be  destroyed  by  active  meas- 
ures lest  they  attain  a  size  too  large  for  surgery  to  manage.  The 
simple  nonproliferative  type  may  be  destroyed  by  the  use  of  the 
x-ray.  I  have  sometimes  Avondered  whether  the  x-ray,  in  obliterat- 
ing these  growths,  might  at  the  same  time  induce  deleterious 
changes  in  the  brain  substance  beneath.  My  disposition  is  to  rec- 
ommend the  use  of  the  x-ray  only  in  growths  situated  on  the  face. 


Fig.  2. — Hemangioma   showing  a   large    number   of   deeply   staining  cells   between   the   vessels. 

CASE  2. — A  baby  of  three  months  old  was  brought  to  the  hospital 
because  of  a  small  tumor  on  the  top  of  the  head. 

History. — This  child  is  the  seventh  of  the  family.  The  preceding 
children  are  all  healthy  and  without  defect.  This  child,  save  for  the 
tumor  in  question,  seems  perfect.  The  tumor  was  noticed  soon  after 
birth,  and  has  not  grown  much  faster  than  the  child.  It  has  been 
noted  that  the  tumor  becomes  markedly  larger  when  the  child 
cries. 

Exami7iation. — A  tumor  Yo  x  %  inch  is  situated  directly  over  the 
great  fontanelle  (Fig.  3).  It  is  ovoid  in  outline  and  about  half 
as  high  as  broad.    The  skin  over  it  is  unchanged  but  less  freely  mov- 


DISEASES    OF    THE    CRANIUM    AND    CONTENTS 


31 


able  over  it  than  over  the  cranial  bones.  It  is  pulsating,  soft  and 
compressible,  permitting  the  fontanelle  to  be  palpated  as  though  no 
tumor  existed.  "When  the  child  cries  the  tumor  becomes  more  tense 
and  then  appears  bluish  in  color.  The  degree  of  blueness  varies 
in  different  parts  of  the  tumor  so  that  a  mottling  appears. 

Diagnosis. — At  first  sight  the  suggestion  was  of  a  meningocele 
but  this  could  be  excluded  because  meningocele  does  not  occur 
over  the  great  fontanelle.  Dermoids  and  angiomas  alone  appear 
here.  Dermoids  sometimes  extend  to  the  dura.  This  tumor,  unlike 
a  dermoid,  expands  in  all  directions  when  the  child  cries.  It 
becomes  a  mottled  blue  when  tense,  which  a  dermoid  could  not  do. 
The  conclusion  remains  that  it  must  be  a  hemangioma. 


Hemangioma  of  the  great  fontanelle. 


Treatment. — Inasmuch  as  this  lay  over  the  brain,  I  feared  to 
recommend  the  use  of  x-raj^s.  Therefore,  the  patient  was  allowed 
to  reach  an  age  of  three  years,  when,  after  an  anesthetic  had  been 
administered,  a  solution  of  adrenalin,  10  minims  to  an  ounce  of 
water,  was  injected  about  the  tumor  in  order  to  constrict  the  small 
vessels  so  that  the  important  areas  could  be  more  readily  seen.  The 
vessels  were  exposed  and  caught  up  singly  and  ligated.  Because 
of  the  close  association  with  the  large  sinus  I  feared  to  use  the 
cautery  lest  a  clot  extend  to  the  larger  jdooI  of  blood. 

Pathology. — The  sections  showed  a  typical  hemangioma. 

After-course. — The  late  scar  is  scarcely  visible. 

Co)iiment. — I  was  of  the  opinion  that  a  spontaneous  cure  might 
occur  when  the  fontanelle  closed  but  this  did  not  take  place.     Con- 


IVI  CIJXICAL    SURGERY    I5V    CASK    HISTORIES 

genital  tumors  located  over  the  iuioii  or  glabella  must  be  approached 
with  great  caution  for  they  most  likely  are  meningeal. 

CASE  3. — A  boy  aged  eleven  was  brought  for  advice  regarding 
treatment  for  a  large  boggy  tumor  of  the  right  temple  and  forehead. 

History. — The  patient  had  a  birthmark  covering  the  side  and 
front  of  his  scalp  at  birth.  This  has  continued  to  develop  until  it 
has  reached  its  ])resent  dimensions.  Otherwise  he  has  always  been 
well. 

Examination. — The  frontoparietal  region  is  occupied  by  a  soft, 
compressible  tumor    (Fig.  4).     Large,   bluish  channels   can  be  seen 


Fig.  4. — Cavernous  hemangioma  of  the  temporal  region. 

through  the  skin,  particularly  at  the  posterior  border  of  the  mass. 
There. is  no  pulsation,  but  the  tumor  can  be  made  to  disappear  by 
compression. 

Diagnosis. — The  compressibility,  together  with  the  outlines  of  the 
channels,  obvious  on  inspection,  make  the  diagnosis  easy.  The  rela- 
tion of  the  mass  to  the  interior  of  the  cranium  is  less  obvious.  The 
whole  mass  seems  fairly  freely  movable  over  the  skull  which  makes 
it  likely  that  there  are  no  large  vessels  connecting  the  tumor  with 
the  interior  of  the  skull.  The  x-ray  shows  no  obvious  openings  in 
the  cranial  vault.  It  is  assumed,  therefore,  that  there  are  few  or 
no  large  vessels  extending  between  the  mass  and  the  vascular  si- 
nuses within  the  cranium. 


DISEASES   OF    THE    CRANIUM    AND    CONTENTS  33 

Treatment. — Because  of  the  apparent  absence  of  intracranial  com- 
munications I  recommended  that  the  surgeon  who  asked  my  advice 
make  an  incision  posterior  to  the  mass,  carefully  elevate  it  from  the 
skull,  and  pack  the  space  so  made  between  tumor  and  skull  with 
gauze  until  the  venous  channels  should  become  obliterated.  The 
advice  was  not  good.     Large  channels  passed  from  the  venous  si- 


Fig.   5. — Large  foramina  showing  the  site  of  the  perforating  veins. 

nuses  to  the  interior  of  the  skull.  AVhen  one  of  these  was  opened 
air  entered  and  the  patient  died  suddenly. 

Pathology. — The  large  openings  in  the  skull  are  seen  in  the  cut  (Fig. 
5).    There  were  no  other  anomalies. 

Comment. — The  x-ray  should  have  shown  these  openings,  though 
in  a  lateral  view"  onh^,  this  was  not  to  be  expected.  Had  their 
presence  been  known  I  should  not  have  advised  this  plan  of 
treatment.  The  error  in  judgment  occurred  because  attention  was 
not  paid  to  the  point  where  connecting  vessels  were  most  to  be  ex- 


;{-!:  (  l.ixicAL  srK(ii:KV   l;v   cAsi.   iiis-roKii-.s 

pectod,  over  tlie  jii'cat  fontanelle.  Tlie  tumor  mass  was  movable 
over  the  tempoparietal  rooion  and  the  relation  over  the  vertex  was 
not  sufficiently  noted.  If  durino-  the  course  of  such  an  operation 
a  large  vein  is  seen  to  enter  the  skull,  the  vessels  should  be  gently 
packed  against  and  tlie  operation  suspended.  AVith  care  such  vessels 
may  be  isolated,  ligated  and  then  cut.  They  are  exceedingly  thin 
walled,  and  great  delicacy  of  manipulation  must  be  practiced. 
Fractional  obliteration  by  means  of  hot  Avater  would  have  been 
safer,  possibly  in  conjunction  with  ligation  of  some  of  the  larger 
channels  at  the  periphery.  The  water  boiling  hot  must  be  injected 
between  and  not  into  the  vessels.  It  is  desirable  to  secure  oblitera- 
tion by  the  production  of  a  phlebitis  and  not  by  an  intravenous  clot. 
Bevan  has  recently  recommended  the  ligation  of  the  common  car- 
otid artery  and  jugular  vein  in  such  casps.  This  is  in  itself  a  some- 
what formidable  procedure. 

CASE  4. — A  matron  of  forty-four  came  to  the  hospital  because 
of  a  large  sloughing-  ulcer  on  the  right  side  of  the  forehead. 

History. — About  nine  years  ago  she  noticed  a  small  red  spot  on 
the  right  side  of  the  forehead  just  above  her  eye.  This  would  be- 
come crusted,  clean  off  smooth  for  a  time,  but  never  entirely  disap- 
peared. It  gave  no  pain  but  became  somewhat  larger  in  the  nine  years. 
About  ten  weeks  ago  she  began  to  be  treated  by  a  local  doctor.  He 
gave  her  tablets  to  dissolve  in  water  to  use  as  a  wash  every  half 
hour  for  4  or  5  days.  He  then  started  to  treat  her  Avith  tlie  x-ray. 
He  gave  her  an  x-ray  treatment  every  other  day  for  seven  weeks. 
At  the  end  of  that  time,  about  two  weeks  ago,  a  black  spot  ap- 
peared in  the  center  of  the  exposed  area.  The  x-ray  treatment  was 
stopped,  but  the  black  area  increased  in  size  until  its  present  dimen- 
sions were  reached.  It  causes  her  some  pain  and  the  right  eye 
feels  very  sore.  She  has  lost  50  pounds  in  the  last  eight  weeks.  Her 
general  health  has  always  been  good. 

Examination.— There  is  a  sloughing  area  ou  the  right  side  of  the 
forehead  almost  circular  in  outline,  51^  cm.  by  7  cm.  in  size.  Its 
edges  are  sharply  defined  as  though  cut  out  by  a  punch  (Fig.  6A). 
In  the  center  is  a  black  sloughing  crust  which  is  very  hard.  Around 
its  edges  is  a  circle  of  foul-smelling  pus.  The  ulcer  edge  is  sharply 
defined,  coming  to  within  a  quarter  of  an  inch  from  the  black  slough- 
ing center.     The  skin  around  the  ulcer  is  inflamed  for  about  one- 


disp:ases  of  the  ckaxii'm  and  contents 


6i) 


half  inch.  Because  of  the  dried  incrustation  it  is  impossible  to  de- 
termine the  condition  of  the  underlying  bone.  General  condition 
is  entirely  without  interest. 

Diagnosis. — The  patient  brings  the  diagnosis  with  her.  It  is  quite 
unusual  to  see  an  x-ray  burn  with  such  a  sharply  detined  border.  The 
reddened  area  of  skin  about  the  ulcer  is  no  more  than  would  be  ex- 
pected from  the  neighboring  suppuratiA'e  process.  Because  of  the 
unusual  features  of  the  case  it  seems  best  to  play  for  a  time  the  role 
of  the  innocent  bystander. 

Treatment. — The  patient  was,  therefore,  kept  in  the  hospital  for 
eight  davs  for  observation  in  order  to  note  anv  change  that  might 


Fig.    6-A. — Necrotic    area    of    the    foreliead 
produced    by    a   cancer    quack's   plaster. 


Fig.    6- 


-The    preceding   after    the    defect 
was    repaired. 


take  place.  In  the  time  she  was  in  the  hospital  no  change  could 
be  observed  in  the  area  or  around  the  edge.  The  skin  maintained 
its  dull  red  inflamed  look  and  no  granulations  started  around  the 
edge  of  the  slough.  The  patient  was  then  dismissed  and  given  a 
10  per  cent  Balsam  of  Peru  ointment  with  instructions  to  return  for 
observation  every  two  weeks. 

Re-entry. — The  patient  returned  to  the  hospital  in  two  weeks  as  re- 
quested. The  black  slough  above  mentioned  separated  about  a  week 
ago  leaving  an  area  of  bone  exposed.  There  are  a  few  granulations 
around  the  edges  of  the  exposed  area  but  for  the  most  part  the  entire 
surface  shows  no  effort  at  healing.     The  surrounding  skin  seems  pos- 


36  CLIXICAIi    Sl-RGKRY    BY    CASE    HISTORIES 

sessed  of  a  good  circulation  and  the  inner  tahle  of  the  sknll  seems  not 
to  be  affected.  It  is  proposed,  tlierefore,  to  remove  the  dead  bone 
down  to  the  diploe  and  cover  the  defect  with  grafts.  The  sknll 
was  dry  and  white  in  appearance.  After  the  outer  table  was  chiseled 
off  the  diploe  bled  rather  profusely  showing  normal  bone  tissue  be- 
neath. Instead  of  grafting  the  exposed  bone  direct  it  seemed  best 
to  shift  a  flap  from  the  temporal  region  and  fill  in  the  defect  so  pro- 
duced in  the  temporal  region  with  Thiersch  grafts. 

After-course. — Practically  no  postoperative  pain  or  other  dis- 
turbance. Six  days  after  operation  the  Thiersch  grafts  seemed 
to  be  growing  (Fig.  6).  The  skin  flap  was  healing  in  place  and  the 
circulation  to  this  part  seemed  sufficient. 

Comment. — The  interest  in  this  case  centers  in  two  points.  It  was 
subsequently  learned  that  while  the  x-rays  were  used,  as  stated,  the 
agency  that  produced  the  slough  was  a  plaster  in  the  hands  of  a 
cancer  quack.  We  learned  this  indirectly  from  another  patient 
who  received  a  similar  lesion  at  the  same  time.  The  wholly  atypical 
x-ray  burn  turns  out  not  to  be  such.  The  other  point  of  interest 
has  to  do  with  the  nature  of  the  flap.  As  the  head  lay  ready  for  the 
operation  to  begin,  the  nice  smooth  skin  of  the  temporal  region 
seemed  the  logical  material  for  filling  in  the  defect  in  the  forehead. 
The  hair  could  then  be  so  arranged  to  cover  the  hairless  region  in  the 
temple  it  was  argued.  ]\Iueh  to  my  discomfiture,  it  was  noted  later 
that  the  flap  in  its  new  position  over  the  eye  was  growing  hair. 
This  possibility  had  entirely  escaped  me  in  my  preoperative  cogita- 
tions.    Some  means  must  now  be  employed  to  destroy  the  hair. 

CASE  5. — A  boy  of  fourteen  was  brought  to  the  hospital  because 
of  a  disfigTiring  tumor  of  the  forehead. 

History. — Since  birth  the  patient  has  had  a  flat,  Ijluish  tumor  on  his 
forehead.  It  has  caused  him  no  inconvenience  save  for  the  embar- 
rassment of  its  appearance. 

Examination.— A  mass  two  inches  in  diameter  occupies  the  forehead 
just  below  the  hair  line.  It  is  elevated  half  an  inch.  It  is  easily 
compressible,  but  returns  instantly  when  the  pressure  is  removed. 
The  skin  over  the  summit  of  the  tumor  is  intimately  attached  to  it. 
This  area  is  bluish,  but  it  becomes  bleached  when  the  tumor  is  com- 
pressed with  a  glass  slide. 


DISEASES    OF    THE    CRANIUM    AND    CONTENTS 


37 


Diagnosis. — The  discoloration  on  pressure  jnst  mentioned  proves 
that  the  blueness  of  the  tumor  is  due  to  contents  of  cavities  which  are 
emptied  by  the  pressure  exerted.  This  is  sufficient  to  stamp  it  as 
a  venous  cavernoma  or  angioma. 

Treatment. — In  order  to  avoid  the  scarring  produced  by  excision 
a  technic  illustrated  in  the  following  figures  was  devised  and  followed. 


Fia 


7. — Technic   of   an   operation   for   the    subcutaneous   removal   of   angiomas   by   preliminary 
ligation  of  the   vessels,   removal   of  the  tumor  and   restoration   of  the   flap. 


An  incision  was  made  along  the  hair  line  and  curving  about  the 
margin  of  the  tumor.  The  skin  was  carefully  incised  until  the 
veins  were  exposed  (Fig.  7A).  These  were  caught  up  each  by  two 
forceps  and  cut  across  and  both  ends  ligated.  The  incision  was  then 
extended  down  to  the  bone.     The  tumor,  together  with  the  skin,  was 


CLIXICATi    SFRGKRV    BY    CASE    HISTORIES 


olevati'd  from  the  bone  until  the  lower  border  of  the  tumor  was 
reached.  The  veins  were  here 'aji-ain  carefully  ligated  (Fig.  7B). 
The  tumor  was  then  dissected  from  the  skin  (Fig.  7C).  After  this 
is  accomplished  the  skin  is  replaced  and  sutured    (Fig.  7D). 

Pathoiogij. — The  tumor  (Fig.  8)  consists  of  a  conglomerate  mass 
of  dilated  vessels  and  connective  tissue. 

Aficr-coursc. — Healing  was  promi)t.  The  sutures  were  removed 
on  the  third  day.     This  patient  is  now  a  grown  man.     The  scar  is 


Fig.   S. — The  angioma  aiu 


r   Hi    ririiioval. 


SO   fine   that    close    inspection   is   recpiired    in    order   to    discover   its 
presence. 

Comment. — When  a  really  competent  roentgenologist  is  available 
the  smaller  of  these  growths  are  best  referred  to  him.  In  larger  ones, 
particularly  in  older  persons,  the  method  here  described  may  be  ad- 
vantageously employed.  It  has  the  advantage  of  being  certain  of 
results  and  of  requiring  but  one  sitting.  It  is  easiest  performed  un- 
der local  anesthesia.  Even  when  a  general  anesthetic  is  required,  as 
in  children,  it  is  advantageous  to  edematize  the  tissue  mildly  with  an 
adrenalin  solution  of  eight  minims  to  the  ounce  of  normal  salt  solu- 
tion in  order  to  constrict  the  smaller  vessels.    This  technic  is  particu- 


DISEASES    OF    THE    CRANIUM    AND    CONTENTS  39 

larly  applicable  in  those  cases  in  which  the  overlying  skin  is  fairly 
well  preserved. 

CASE  6. — A  matron  aged  sixty-five  came  to  the  hospital  because 
of  a  tumor  on  the  back  of  her  head. 

History. — For  six  months  she  has  noticed  a  tumor  developing 
in  the  scalp.  It  is  causing  some  pain  and  is  very  much  in  the  way, 
since  she  is  unable  to  lie  on  her  back  with  comfort.  Her  general 
health  is  good.  The  patient  has  had  four  children  all  of  whom  she 
nursed  without  incident.  She  passed  the  menopause  seventeen  years 
agt)  and  has  been  free  from  pelvic  symptoms  since. 

Examination. — A  tumor  the  size  of  an  unhuUed  walnut  occupies 
a  site  near  the  external  occipital  protuberance.  It  is  somewhat  bosse- 
lated,  very  hard,  with  pseudoencapsulations.  It  is  somewhat  fixed 
to  the  skin  but  not  a  part  of  it.  It  is  obviously  a  carcinoma,  and 
since  it  is  not  a  part  of  the  skin,  has  not  developed  from  this  site. 
Search  for  a  primary  tumor  discloses  a  marked  shriveling  of  the 
breast  with  retraction  of  the  nipple  and  marked  puckering  of  the 
skin  over  an  area  the  size  of  a  dollar.  This  shriveling  of  the  breast 
she  admits  has  been  present  a  number  of  years,  but  regards  it  as  of 
no  consequence. 

Diagnosis. — As  a  secondary  carcinoma  this  tumor  must  be  differ- 
entiated from  benign  epithelioma.  The  latter  do  not  grow  as  large 
in  six  months  as  this  one  now  is,  and  the  skin  is  intimately  attached  to 
them.  Sarcomas  have  intimate  attachment  to  the  fascia  and  may  in- 
vade the  skin,  but  do  not  become  attached  to  it.  Wens  sometimes 
become  malignant,  but  they  do  so  only  after  years  of  innocent  exist- 
ence, and  when  they  do  so,  it  is  about  the  base  and  not  throughout 
the  whole  tumor  that  the  malignant  changes  occur.  The  laboratory 
findings  indicate  a  mild  interstitial  nephritis.  With  the  discovery 
of  the  lesion  of  the  breast  the  naming  of  the  tumor  in  the  scalp  offers 
no  difficulties.  Since  the  patient  desires  the  removal  of  the  tumor,  her 
wish  may  be  gratified  purely  as  a  temporary  relief  frOm  a  minor  con- 
sideration. 

Treatment. — The  patient  was  told  that  cure  was  impossible,  but 
she  desires  the  tumor  removed  as  a  temporary  convenience.  This 
was  done. 


40 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


Pathology. — A  dense  mass  showing  many  fine,  interminoied  whitish- 
grey  dots,  whieli  on  section  showed  a  carcinoma  simplex    (Fig.  9). 

After-course. — There  were  no  recurrences  on  her  head;  and  the 
breast  remained  nnchanged.  Some  time  after  the  operation  many 
tumors  developed  in  the  skin  on  tlu^  back.  8he  died  a  year  and  a  half 
later  of  exhaustion. 

Comment. — Schirrus  breast  cancers  not  infrequently  give  rise  to 
distant  metastases.     When  carcinomas,  particularly  dense  ones,  are 


Fig.  9. — Carcinoma  of  the  scalp  from  a  breast  tumor. 

discovered  in  unusual  situations  in  the  body,  the  breast  is  the  first 
organ  to  be  interrogated. 

CASE  7. — A  salesw^oman  aged  thirty-two  came  to  me  because  of 
ulcers  on  her  forehead. 

Ilistory. — Four  months  ago  she  noticed  a  lump  on  her  forehead. 
It  was  hard  and  painful  as  though  due  to  a  bump.  Though  she  did 
not  remember  having  bumped  herself  she  accepted  an  accident  as  a 
probable  cause  which  may  have  a  poetic  truth.  Some  weeks  later  other 
bumps  appeared.  Two  months  ago  the  first  one  softened  and,  in  a 
week  or  two,  ulcerated.  Then  others  ran  a  similar  course.  She  was 
treated  Avith  various  salves  and  the  two  first  formed  have  started  to 
heal.     She  has  painful  menstruation  and  occasionally  severe  pains 


DISEASES    OF    THE    CRANIUM   AND    CONTENTS 


41 


half  way  between  the  menstrual  periods.  She  had  bladder  irrita- 
tion some  years  ago,  but  now,  save  for  getting  up  once  at  night,  she 
has  no  trouble.     She  has  had  no  throat  or  skin  diseases. 

Examination. — The  patient  has  a  sallow,  muddy  complexion,  and  a 
weary  look  in  otherwise  intelligent  eyes.  Above  the  root  of  the  nose 
there  are  two  ulcers  partly  healed,  and  to  the  left,  just  above  the 
eyes  are  two  others  which  have  soft,  undermined  edges  and  a  dirty, 
moist,  granular  floor.  In  the  depth  of  these  the  bone  is  exposed. 
The  outline  of  the  larger  and  more  recent  one  is  definitely  reni- 
form  (Fig.  10 — a  photograph  could  not  be  used  for  the  purposes  of 


Fig.   10. — Syphilitic  ulcerations  of  the  foiehead. 

illustration  for  obvious  reasons).  There  is  but  little  pain  on  pressure. 
The  blood  examination  shows  a  slight  general  anemia  and  the  urine  a 
good  many  pus  cells. 

Diagnosis. — The  question  of  diagnosis  involves  only  syphilis  and 
tuberculosis.  The  patient  has  the  general  aspect  of  a  vigorous  consti- 
tution with  no  evidence  of  tuberculosis  elsewhere.  The  lesions  are 
multiple,  cranial  tuberculosis  is  usually  single.  Tuberculosis  usually 
involves  the  bone  over  a  wider  area  than  the  soft  parts  would  indicate. 
Here  the  bone  seems  merely  exposed  and  not  actively  diseased.  Tu- 
berculous lesions  are  never  renif  orm ;  syphilitic  ones  usually  are ; 
syphilis  is  painful  in  the  beginning,  tuberculosis  is  not.     The  form  of 


42  (LIXKAr.    SLRGKKV    UY    CASE    HISTORIES 

the  larger  lesion  is  distinctive  of  syphilis  without  further  evidence. 
No  Wassennann  is  needed  when  so  labeled. 

Treatment. — ^Mercurial  ointment  was  used  local  1\'.  and  potassium 
iodide  internally  for  three  weeks,  then  mercury. 

After-course. — The  local  lesion  healed  promptly. 

Comment. — Syphilitic  lesions  of  the  scalp  are  relatively  rare,  and 
when  solitary,  may  offer  some  difficulty  in  diagnosis.  In  such  cases 
the  Wassermann  reaction  would,  of  course,  be  in  order.  To  employ 
it  in  such  a  case  as  this  would  l)e  putting  the  reaction  on  trial  and 
not  the  disease.  When  ])ositive,  the  clinical  features  of  syphilis  are 
more  to  be  depended  on  than  the  AVassermann  reaction.  Laboratory 
men  sometimes  overlook  this  very  obvious  fact. 

CASE  8. — A  girl  of  eighteen,  an  employee  of  a  candy  factory, 
came  to  me  because  of  a  swelling  on  her  forehead. 

History. — For  a  number  of  months  she  has  noticed  a  swelling  on 
her  forehead.  It  has  not  caused  pain,  but  has  gradually  enlarged. 
Recently  it  has  developed  quite  rapidly  and  the  surface  has  become 
discolored.  The  plant  physician  diagnosed  a  wen  and  advised  its 
removal.  She  has  had  numerous  diseases  of  childhood,  including 
whooping  cough,  diphtheria  and  scarlet  fever.  She  has  had  frequent 
attacks  of  tonsillitis.  Her  father  is  unable  to  Avork  because  of  lung 
trouble. 

Examination. — The  patient  has  a  waxen  pale  complexion.  She 
seems  emaciated  but  states  she  weighs  97  pounds,  which  is  about  all 
she  has  ever  weighed.  She  has  a  hemispherical  tumor  situated  just 
to  the  left  of  the  median  line  and  below  the  hair  margin.  The  sides 
are  slanting,  coming  to  the  apex  at  a  low  angle.  The  apex  is 
reddish  blue  in  color  over  an  area  1  cm.  across.  The  surrounding 
skin  is  imaffected.  The  tumor  is  soft  and  fluctuating.  The  border 
seems  more  indurated  than  does  the  margin  of  the  tumor.  She  has 
a  chain  of  lymphatic  glands  on  either  side  of  the  neck.  The  tonsils 
are  enlarged.     Physical  examination  otherwise  is  negative. 

Diagnosis. — The  gradual  onset,  its  painless  course  and  the  patient's 
general  appearance  suggests  cranial  tuberculosis.  From  syphilis  it  is 
distinguished  by  its  painless  course  and  by  the  length  of  time  re- 
quired for  its  development.  From  wens  it  is  distinguished  by  the 
form,  its  course  of  development,  and  by  the  character  of  the  contents 
as  manifest  on  palpation.    Wens  may  break  down  and  give  the  gen- 


DISEASES    OF    THE    CRANIUM    AND    CONTENTS  43 

eral  appearance  of  tuberculosis,  but  usually  there  is  the  history  of  a 
long  existing  tumor  and  usualh^  too,  the  wen  can  be  moved  about 
over  the  underlying  bone  while  tuberculosis  is  intimately  attached  to 
it.  Because  the  skin  is  near  the  point  of  rupture  it  seems  best  to 
open  freely  and  remove  as  much  of  the  disease  as  possible. 

Treatment. — The  skin  was  freely  incised  which  allowed  a  thin  pus 
containing  many  greyish  tlocculi  to  escape.  The  bone  was  exposed 
and  the  curette  readily  elevated  many  particles,  leaving  a  granular 
place  with  a  bony  base,  probably  the  inner  table  of  the  skull.  An 
area  as  large  as  half  a  dollar  was  so  exposed  with  slight  effort  with 
a  mastoid  curette.  AVlien  thoroughly  cleaned  out,  it  was  treated  with 
carbolic  acid  and  alcohol. 

Pathology. — The  material  removed  consisted  of  granulation  tissue 
with  many  particles  of  bone.  These  bone  particles  were  more  or  less 
globular  or  cuboidal  and  were  surrounded  by  granulation  tissue.  On 
inspection  they  appeared  as  masses  of  granulation  tissue  and  only 
when  pressed  between  the  fingers  did  the  bony  content  make  itself 
manifest. 

After-course. — Healing  took  place  promptly  and  remained  perma- 
nently. 

Comment. — Had  the  skin  been  uninvolved,  I  should  have  aspirated 
and  injected  iodoform  glycerine.  Active  treatment  is  apt  to  produce 
an  extension  of  the  process  to  previously  unaffected  areas.  Other- 
wise surgical  treatment  is  preferable  because  recovery  is  very  much 
expedited.  Usually  the  process  begins  in  the  diploe  and  simultane- 
ously destroys  both  tables.  Therefore  when  the  disease  is  attacked,  the 
dura  is  reached  at  once.  In  some  instances  new  bone  may  have 
formed  over  the  dura,  it  is  said. 

CASE  9. — A  man  aged  thirty-three  entered  the  hospital  because  of 
a  tumor  on  the  back  of  his  head. 

History. — For  a  year  or  more  the  patient  has  had  a  tumor  back 
of  his  left  ear.  It  grew  gradually,  until  two  months  ago  it  had  at- 
tained the  size  of  a  walnut.  His  doctor  diagnosticated  a  wen  and 
proceeded  to  remove  it  under  local  anesthesia.  He  was  surprised  to 
find  a  solid  tumor  surrounded  by  several  very  large  blood  vessels. 
He  made  a  strategic  retreat.  In  the  two  months  which  have  inter- 
vened, the  tumor  has  attained  the  size  of  a  small  orange. 


44 


CLINICAL   SURGERY   BY    CASE   HISTORIES 


Examination. — A  tumor  occupies  the  region  between  the  mastoid 
process  and  the  external  occipital  protuberance  (Fig.  11).  The  skin 
is  movable  over  the  lower  half  of  the  tumor  while  the  half  toward  the 
summit  is  incoriiorated  in  the  growth.  The  tumor  is  movable  upon 
the  skull.  The  postcervieal  lymph  glands  are  enlarged  to  the  size  of 
butter  beans.     Those  lying  more  deeply  are  barely  palpable. 

Diagnosis. — The  solid  tumors  of  the  scalp  are  usually  endothe- 
liomas.    They  have  a  sarcomatous  arrangement,  tend  persistently  to 


Fig.   11. — Sarcoma  of  the  scalp. 

return,  and  metastasize  b}-  way  of  the  lymphatics.  The  skin  over 
their  surface  is  often  thinned,  resembling  that  of  spina  bifida.  This 
tumor  seems  to  fit  this  category.  This  type  of  tumor  usually  is  inti- 
mately attached  to  the  skin,  a  fact  often  made  evident  by  a  fine  cap- 
illary network.  Those  who  depend  on  this  sign  to  identify  wens  are 
often  mislead.  These  tumors  are  more  dense  than  wens  and  are  not 
so  completely  encapsulated. 

Treatment. — The  upper  cervical  lymph  glands  were  blocked  out, 
and  the  incision  extended  upward  to  circumscribe  the  tumor.  The 
incision  made  to  expose  the  lymph  glands  was  used  for  the  anterior 


DISEASES    OF    THE    CRAXIUM    AXD    CONTEXTS 


45 


line  in  making  a  flap  to  cover  the  defect  made  in  the  removal  of 
the  tnmor.  The  defect  left  by  dislocating  the  flap  was  covered  by 
skin  grafts. 

PatJiologij. — The  tumor  is  made  up  of  large  round  cells.  Only  in 
the  older  parts  of  the  tnmor  is  the  spindleform  shown.  The  lymph 
glands  also  show  the  large  round  cells.  The  cells  usually  are  ar- 
ranged in  groups  and  this  together  with  their  close  association  with 


Fig.   12. — Section   from   case   shown   in   Fig.    11    showing  arrangement    of   cells   about    a   blood 

vessel. 


the  skin  suggests  a  relationship  to  the  chromatophore  group  of  tumors. 
Their  disposition  to  spread  by  way  of  the  lymphatics  also  harmonizes 
with  such  an  assumption.  The  arrangement  about  the  vessels  (Fig. 
12)  suggests  a  perithelioma. 

After-course. — In  two  months  recurrences  appeared  in  the  skin  of 
the  occiput  above  the  incision  and  more  lymph  glands  were  palpa- 
ble. These  recurrences  were  excised  with  the  result  of  stimulating 
the  tumor  to  renewed  growth.  He  died  six  months  after  the  first 
operation. 


46  c  i.iMcAi,  srij(;i:KY  i-.v  cAsi:  iiistoriks 

Couinicnf. — These  tumors  are  often  but  of  moderate  malig:naucy 
and  offer  a  fair  prognosis  by  radical  operation.  Despite  the  presence 
of  metastasis,  a  trial  seemed  worth  while.  When  I  saw  the  type  of 
cell.  I  realized  the  hopelessness  of  the  task.     Not  withstanding  this, 

1  attempted  to  remove  the  recurrences,  inspired  beyond  my  better 
knowledge  by  the  magnificent  courage  of  the  man.  Lowly  in  life 
and  simjile  at  heart.  1)ut  lofty  of  ^^urpose,  he  asked  for  a  chance  in  a 
thousand.  If  such  a  case  is  undertaken  at  all,  a  complete  block  dis- 
section of  the  neck  from  clavicle  to  mastoid  should  be  done  as  the 
first  act  and  the  removal  of  the  tumor  deferred  to  a  second  operation. 
It  is  rarely  that  a  patient  is  rescued  once  the  cervical  lymphatics 
are  affected  by  a  malignant  growtli.  Init  I  have  several  times  succeeded 
in  curing  this  type  of  tumor  after  the  lymph  glands  had  become  in- 
volved, in  one  instance  after  seven  operations. 

DISEASES   OF  THE   CRANIAL   CONTENTS 

Unless  the  surgeon  be  an  expert  in  brain  diseases,  he  should  con- 
fine his  diagnostic  efrorts  to  the  recognition  of  the  emergencies. 
In  these  cases  he  must  be  prepared  to  act  or  fail  to  act.  with  prompt- 
ness and  decision,  for  they  are  often  but  a  part  of  a  number  of 
surgical  lesions  as  in  the  case  of  accidents.  In  cases  of  chronic  dis- 
ease he  will  do  well  to  place  the  burden  of  localization  on  the  neurol- 
ogist. It  is  highly  desirable,  however,  that  the  surgeon  be  so  trained 
as  to  enable  his  mind  to  go  along  with  that  of  his  consultant  in  order 
that  he  may  have  a  clear  conception  of  the  technical  difficulties  in- 
volved and  the  anatomic  results  to  be  obtained.  Besides  the  fact  that 
the  neurologist  possesses  a  greater  diagnostic  skill,  the  after  care  is 
such  as  to  require  the  constant  care  of  a  neurologist ;  also,  since  the 
lesions  are  usually  incurable,  the  neurologist,  being  inured  to  the 
management  of  the  incurable,  is  temperamentally  better  fitted  to 
conduct  the  unfortunate  patient  to  the  inevitable  end. 

CASE  1. — A  farmer  aged  thirty-seven  years  was  brought  to 
the  hospital  in  an  unconscious  state. 

History. — One  week  ago  the  patient  fractured  his  thigh  by  being 
pinched  between  two  wagons.    It  was  set  three  hours  later.    For  this 

2  ounces  of  chloroform  were  given.  Deep  anesthesia  did  not  last  over 
ten  minutes,  and  he  was  fully  conscions  30  minutes  later.    During  the 


DISEASES    OF    THE    CRANIUM    AND    CONTENTS 


47 


following  day  he  received  two  1/8  grain  morphine  tablets  seven 
hours  apart.  He  had  been  nauseated  at  intervals.  On  the  sec- 
ond da}^  he  became  drowsy,  but  answered  questions.  On  the  third 
day  urine  was  passed  involuntarily.  His  pulse  and  temperature 
were   recorded   by   his   physician   as   normal.      Though   he   could  be 


Fig.    13. — Section    of   the   liver    in   delayed   chloroform   poisoning   showing   the   intralobular   de- 
generation. 


roused  but  little  if  at  all,  his  eyes  would  follow  movements  of  at- 
tendants about  the  room.  He  took  some  food  when  urged  to  do  so. 
He  had  attacks  of  hiccoughs  at  intervals.  This  condition  remained 
unchanged  until  he  was  brought  to  the  hospital. 

Examination. — The  patient  lies  apparently  oblivious  to  his  environ- 
ment and  does  not  respond  to  questions.     He  seems  to  follow  the 


48 


CLIXICATv    SURGERY    BY    CASE    HISTORIES 


movements  of  the  examiner,  however.  The  skin  is  slightly  janndieed, 
the  pupils  react  feebh^  to  light.  The  pupils  are  equal  and  about  4 
mm.  in  diameter.  The  mouth  contains  much  mucus  and  the  odor 
of  the  breath  is  fetid.  The  tongue  is  covered  with  a  dark,  dry  crust. 
He  breathes  through  his  mouth  entirely.  There  is  no  evidence  of 
trauma.  The  left  thigh  is  encased  in  a  cast.  No  reflexes  can  be 
obtained  from  the  sound  leg  and  Babinski  is  negative.  Bp.  100-80, 
urine  negative.    Respiration  48,  pulse  145,  temperature  100°. 


Fig.   14.^Section  through  the  pons  in  delayed  chloroform  poisoning  showing  petechial  hemor- 
rhage  and   perivascular   degeneration. 


Diagnosis. — "Wlien  a  patient  becomes  unconscious  following  a  frac- 
ture, particularly  a  fracture  of  the  femur,  fat  embolism  is  probable. 
However,  the  onset  is  sudden,  the  pulse  very  rapid,  and  usually  there 
is  dyspnea.  In  this  case  the  onset  was  slow  and  his  doctor  states 
his  pulse  and  temperature  were  normal  after  the  condition  was  well 
developed.  The  icteric  tinge  of  the  skin  and  sclera  recalls  that  he  got 
two  ounces  of  chloroform  before  the  onset  of  the  mental  hebetude. 
The  rapid  respiration  and  pulse  is  evidently  that  of  impending  dis- 
solution.    The  slow  onset  with  the  partial  or  recurrent  unconscious- 


DISEASES    OP    THE    CRAXII'IM    AXD    COXTEXTS 


49 


ness  corresponds  to  chloroform  poisoning.  The  onset  on  the  second 
day  with  threatening  dissolution  at  the  end  of  a  week  is  in  harmony 
with  this  theory.    The  nrine  gives  no  reason  to  suspect  uremia. 

Treatment. — General  care,  no  medication  except  strychnine. 

After-course. — The  hebetude  continued  to  increase  and  he  died 
eighteen  hours  after  entering  the  hospital. 

Autopsy. — Bases  of  the  lungs  are  congested  but  float.  The  liver 
is  small,  the  surface  is  mottled  yellowish  grey   (Fig.  13).     The  dura 


Fig.    lo. — Degeneration    of   the   liver   in    delayed    chloroform    poisoning. 


shows  no  changes,  but  the  cut  surface  of  the  brain  shows  many 
petechia  (Fig.  14).  The  slides  show  congestion  in  the  bases  of  the 
lungs  and  many  of  the  alveoli  contain  blood.  A  slide  of  the  liver  shows 
distinct  central  changes,  fat  and  pigment  deposition  and  marked  ne- 
crosis of  the  parenchyma  cells  in  many  regions  (Fig.  15).  The  brain 
shows  numerous  small  petechial  hemorrhages  and  areas  of  perivascu- 
lar degeneration  which  are  particularly  marked  in  the  medulla  (Fig. 
16).     In  none  of  the  vessels  could  fat  be  demonstrated. 

Comment. — This  represents  a  typical  delayed  chloroform  poison- 
ing, now  fortunatelv  rare,  since  this  anesthetic  is  so  little  used. 


50  CLINICAL    SURGERY    BY    CASE    HISTORIES 

The  changes  in  the  liver  are  typical.  There  is  little  known  of  the 
brain  changes  in  this  condition.  The  hemorrhages  observed  in  this 
case  are  strikingly  like  those  observed  after  death  from  pnerperal 
eclampsia.  The  chief  changes,  however,  are  degenerative,  and  the 
hemorrhagic  areas  likely  are  only  secondary  hemorrhages  into  the 
degenerated  areas. 


Fig.  16. — Perivascular  degeneration  in  delayed  chloroform  poisoning. 

CASE  2. — A  railway  brakeman  aged  twenty-six  was  brought  to 
the  hospital  because  of  a  fracture  of  the  thigh. 

History. — The  patient  Avas  thrown  from  a  moving  train  and  was 
picked  np  nnconscions.  It  was  observed  that  his  right  thigh  was 
broken.  AVhen  he  reached  the  hospital,  four  hours  after  the  accident, 
he  was  mentally  clear  and  there  was  no  evidence  of  cranial  injury. 
There  was  a  comminuted  fracture  of  the  femur  with  a  detached  frag- 
ment of  bone  lying  at  nearly  right  angles  to  the  bone  above  and  below. 
He  was  in  a  degree  of  shock,  Imt  had  recovered  by  the  time  an  x-ray 
plate  of  the  injury  could  be  prepared. 

Examination. — About  eighteen  hours  after  the  injury  he  rather 
suddenly  became  dyspneic,  the  respiration  reaching  38  and  the  pulse 
136.    He  was  delirious  and  was  restrained  with  difficultv.    The  urine 


DISEASES    OF    THE    CRAXIUIM    AXD    COXTEXTS  51 

sliowed  a  trace  of  albumin,  but  no  blood  and  the  specific  gravity  Tras 
1.026.  There  vreve  16,000  leucocytes.  The  pulse  was  quick,  hard,  and 
wiry.  The  respiration  was  labored ;  there  was  some  evidence  of  cyano- 
sis and  there  were  moist  rales  over  the  greater  portion  of  both  lungs. 
The  pupils  were  moderately  dilated  and  reacted  to  light.  The  site 
of  injury  showed  a  comminuted  fracture  with  one  piece  3  inches 
long  displaced  from  contact  with  the  ends  of  the  bones.  Numerous 
small  pieces  occupied  various  relations  to  the  larger  fragment. 

Diagnosis. — The  extent  and  nature  of  the  leg  injury  was  clearly 
apparent  from  the  x-ray.  The  general  condition  was  not  so  clear. 
There  was  early  mental  disturbance  which  cleared  in  a  few  hours  and 
no  fracture  of  the  skull  was  apparent  by  the  x-ray.  The  subsequent 
mental  disturbance  was  regarded  by  the  medical  consultant  as  due  to 
secondary  hemorrhage.  This  seemed  unlikely,  for  he  was  delirious 
from  the  beginning  and  remained  so.  Early  mental  restlessness  is 
sometimes  observed  in  late  hemorrhage,  but  it  subsides  when  the  liem- 
crrhage  increases.  The  pulse  rate  was  rapid  from  the  beginning.  I]i 
hemorrhage  it  is  slow  at  first  and  becomes  rapid  only  late  in  the  dis- 
ease. When  a  rapid  pulse  appears  in  hemorrhage,  the  patient  is  in 
profound  coma.  The  respiration  became  rapid  at  once  and  remained 
the  dominant  feature.  The  sudden  dyspnea  and  the  rapid  pulse  com- 
ing on.  eighteen  hours  after  an  extensive  fracture  suggested  a  fat 
embolism. 

Treatment. — The  fractured  member  was  placed  in  a  temporary 
support.  General  stimulative  measures  were  employed.  He  received 
15  minims  of  tr.  of  strophanthus  when  the  pulse  became  uncountable. 

Suhsequent  Course. — He  regained  consciousness  on  the  fourth  day 
and  the  dyspnea  rapidly  lessened  and  the  temperature  returned 
to  normal.  At  the  end  of  the  second  week  the  fragments  were  replaced 
by  open  operation.  In  order  to  reduce  the  duration  of  ether  anesthe- 
sia, known  to  be  particularly  injurious  to  those  suffering  from  fat 
embolism,  no  mechanical  means  were  employed  to  retain  the  frag- 
ments in  position.  The  operation  lasted  only  a  few  minutes.  He 
stood  the  operation  well,  but  in  six  hours  his  pulse  became  rapid, 
dyspnea  was  extreme,  and  he  became  delirious — an  exact  replica 
of  his  attack  following  the  injury.  This  condition  rapidly  increased 
and  he  died  in  twenty-four  hours  following  the  operation. 


;)2  CLINICAL    RIROKKY    BY    CASE    HISTORIES 

Autopsy. — The  meninovs  were  injected  and  there  were  many  pin- 
point hemorrhapes  just  beneath  the  cortex.  The  basal  ganglia  were 
not  involved.  The  lungs  were  congested,  contained  a  bloody  froth, 
but  all  portions  tioated.  The  solid  parenchymatous  organs  showed 
a  general  congestion.  The  sections  shovred  multiple  fat  thrombi  in 
the  lungs  (Fig.  17)  but  were  not  demonstrated  in  the  brain.  There 
was  some  cloudy  swelling  of  the  kidneys. 

Comment. — A  number  of  errors  were  committed  in  the  manage- 
ment of  the  case.     He  was  transported  a  long  distance  so  that  he 


•4 

>  ^                     '^j*«s^;  -v 

- 

-^ 

Fig.    17. — Fat   embolism   in   the  lung  after  fracture  of  the   femur. 

reached  the  hospital  only  after  four  honrs.  No  adecpiate  temporary 
splint  had  been  applied.  The  operation  was  done  without  an  Es- 
march  constrictor.  There  is  evidence  that  placing  a  constrictor  and 
alloAving  it  to  remain  two  hours  lessens  the  likelihood  of  renewed  em- 
bolism. Ether  was  used  as  an  anesthetic.  Spinal  anesthesia  should 
by  all  odds  have  be?n  used.  Two  weeks  were  allowed  to  elapse 
before  the  operation  was  undertaken.  In  the  interest  of  bone  repair 
it  did  not  seem  well  to  defer  the  replacement  of  the  fragments  longer. 
"Whether  or  not  in  such  cases  it  is  worth  while  to  ligate  the  thoracic 
duct  as  "Wilms  advises  is  a  cpiestion.  I  should  fear  the  prolonged 
operation  would  do  more  harm  than  the  ligation  would  do  good. 


DISEASES    OF    THE    CRANIUM    AND    CONTENTS  53 

CASE  3. — A  teamster  aged  42  was  brought  to  the  hospital  be- 
cause of  delirium  following  injury  to  the  skull. 

History. — Two  weeks  ago  he  was  struck  in  the  side  of  the  head. 
This  caused  an  injury  to  the  scalp  and  temporary  unconsciousness 
followed.  He  was  taken  to  a  hospital  where  the  wound  was  laid 
open  and  some  pieces  of  loose  hone  were  removed.  He  improved  fol- 
lowing this  for  a  week,  but  since  then  he  has  had  fever  and  some  head- 
ache.   For  the  past  twenty-four  hours  he  has  been  delirious  at  times. 

Examination. — The  patient  lies  comatose  for  the  most  part,  but 
rouses  at  intervals  as  if  in  pain.  During  these  restless  periods  he 
uses  the  right  hand  less  than  the  left.  The  pupils  are  wide,  but  react 
to  light,  the  left  less  than  the  right.  The  temperature  is  103.4°, 
"W.B.C.  28,000.     The  wound  in  the  scalj)  contains  pus. 

Diagnosis. — The  local  injury,  the  mental  distress  since,  and  the  leu- 
cocytosis  suggest  a  suppurative  process  in  that  region.  Its  location  and 
extent  must  be  determined  as  the  treatment  progresses. 

Treatment. — The  scalp  wound  was  enlarged,  which  permitted  sev- 
eral loose  fragments  of  bone  to  be  discovered.  The  exposed  dura  was 
deep  red,  and  covered  with  granulations  and  fibrin.  The  bone  was 
removed  until  an  area  of  dura  the  size  of  half  a  dollar  was  exposed. 
It  bulged  into  the  wound,  was  tense  and  pulseless.  An  aspirator  dis- 
covered pus  at  the  depth  of  half  an  inch.  The  area  was  packed  off 
with  iodized  gauze  and  the  dura  opened.  Pus  flowed  freely  when 
the  brain  substance  was  parted  half  an  inch  deep.  A  soft  rubber 
drainage  tube  was  introduced. 

Pathology. — The  culture  showed  staphylococcus,  while  the  smear 
showed  in  addition  a  rod  which  did  not  develop  on  the  culture. 

After-course. — Within  a  few  hours  after  the  operation  the  patient 
declared  himself  as  feeling  well.  In  two  days  he  desired  to  leave  the 
hospital.  Despite  warning  his  physician  removed  the  protecting  pack 
at  the  end  of  forty-eight  hours.  A  violent  septic  meningitis  developed, 
and  in  a  day  he  was  dead. 

Comment. — In  the  drainage  of  brain  abscesses  or  in  operating  an 
infected  fracture  of  the  skull,  the  great  danger  is  in  producing  a 
meningitis.  Had  the  pack  been  allowed  to  remain  a  week  or  ten 
days,  a  diff'erent  result  would  have  been  obtained. 


54  CLINICAL    SURGERY    BY    CASE    HISTORIES 

CASE  4. — I  was  called  to  see  a  man,  aged  forty-five,  because  he 
had  persistent  pain  in  the  left  side  of  his  head  and  neck  following" 
a  mastoid  operation. 

History. — Ten  years  ago  lie  had  a  mastoiditis  on  the  left  side  and 
was  operated  on.  The  wound  healed,  ])nt  the  discharge  from  the  ear 
did  not  stop.  In  the  ten  years  that  followed  he  was  never  sick  and 
had  no  pain  in  the  head  or  ears.  However,  about  four  months  ago 
he  began  to  have  pains  in  the  left  ear  similar  to  that  of  ten  years  be- 
fore. Two  days  later  he  was  operated  on  by  a  competent  specialist, 
and  a  radical  mastoid  operation  was  done.  The  pain  was  not  relieved 
but  continued,  extending  over  tlie  left  side  of  his  head  and  radiating 
to  his  neck.  Since  the  radical  operation  was  done,  now  four  months 
ago,  he  has  been  operated  three  times  in  attempts  to  locate  the  source 
of  the  pain.  The  scalp  of  the  parieto-occipital  region  was  edematous 
and  it  was  concluded  that  the  pain  was  due  to  a  cranial  perio.stitis 
his  surgeon  states.  The  operative  efforts  consisted  in  opening  the 
swelling  at  various  points  on  the  left  side  of  the  head.  Each  incision 
resulted  in  an  increased  drainage  of  pus.  He  has  dull  pains  contin- 
ually, and  every  few  hours  he  has  an  almost  unbearable  paroxysm 
of  pain  whicli  lasts  one-half  to  one  hour  and  is  quieted  only  by  opiates. 
During  tlie  several  days  just  past  he  has  developed  a  temperature 
of  100-102.5'.  and  has  been  stuporous  and  sleeps  heavily  except 
when  aroused  by  paroxysms  of  pain. 

Examination. — He  now  has  an  open  wound  over  the  squamous  part 
of  the  temporal  bone  which  is  draining  pus.  His  greatest  point  of 
tenderness  is  just  back  of,  and  at  the  upper  extremity  of.  the  lobe 
of  the  ear.  His  pulse  is  100  and  his  temperature  101°.  The  pupils 
are  equal,  normal  in  size,  and  react  sluggishly  to  light.  He  is  some- 
what stuporous  and  begs  for  relief.  There  are  no  sensory  or  motor 
symptoms,  save  a  general  increase  of  the  reflexes. 

Diagnosis. — The  continued  pain  following  the  mastoid  operation, 
with  temperature,  makes  it  likely  that  there  is  a  dural  involvement 
and  the  increasing  hebetude  suggests  an  abscess.  Obviously  the  pain 
could  not  be  due  to  periostitis,  since  because  of  the  looseness  of  the 
pericranium,  pain  would  not  be  produced.  Since,  however,  pus  es- 
caped following  the  incisions  through  the  scalp,  an  associated,  deep- 
seated,  suppurating  process  is  suggested.  It  was  deemed  wise  to  open 
1-he  cranium.    He  wa.s,  therefore,  ordered  sent  to  the  hospital. 


DISEASES    OF    THE    CRAXIUM    AXD    COXTEXTS  55 

Treafmeitt. — Au  incisiou  ^A'as  made  over  the  squamous  portion  of 
the  temporal  boue.  The  scalp  "was  found  to  be  almost  comijletely 
separated  from  an  area  of  necrotic  bene.  An  area  3x4  cm.  was 
completely  separated,  and  was  removed  by  lifting'  it  out  with  an  ele- 
vator. A  needle  was  passed  into  the  brain  in  several  directions,  but 
no  pus  was  f  ornid.  It  was  concluded  that  we  had  to  do  with  a  suppura- 
tive meningitis  only.     Two  tubes  and  one  gauze  drain  were  left. 

After-course. — The  pains  were  severe  all  the  week  following  and 
required  opiates  for  their  relief,  but  he  had  none  of  the  severe  parox- 
ysms that  he  had  before  the  operation.  The  pains  gradually  les- 
sened after  this  time  and  after  four  weeks  he  was  free.  The  wounds 
were  healed  and  the  edema  of  the  scalp  had  lessened.  He  was  al- 
lowed to  return  home.  The  ear  was  discharging  freely,  and  there 
was  pain  on  pressure  over  tlie  anterior  left  parietal  region. 

Two  weeks  later  the  patient  was  seen  for  the  first  time  since  leaving 
the  hospital.  The  relatives  called  on  account  of  the  patient's  having 
con-VTilsicns.  The  relatives  reported  that  the  patient  had  felt  pretty 
well  since  ccming  home  except  for  occasional  pain  in  the  head.  Two 
days  before  he  had  been  dull  and  at  times  stuporotis.  About  noon  of 
that  day  he  got  up  and  started  to  dress  but  laid  over  the  bed  and  went 
to  sleep  half  dressed.  That  night  at  nine  o'clock  he  had  his  first 
conMilsion.  "When  seen  at  10 :30  p.  m.  he  had  had  four  or  five  con- 
vulsions. The  patient  was  lying  on  his  back,  staring  around  in  a 
confused  manner.  He  could  not  be  aroused  by  questioning.  His  face 
was  flushed  and  he  was  sweating  profusely.  The  temperature  was 
102°,  the  pulse  110.  full  and  bounding.  The  right  arm  and  leg  were 
limp,  the  left  arm  and  leg  were  partially  flexed.  The  reflexes  were 
exaggerated  on  both  sides,  and  no  Babinski  could  be  definitely  elic- 
ited. The  pupils  were  moderately  dilated,  of  equal  size,  and  responded 
to  light.  Two  con-vmlsions  were  observed  about  fifteen  minutes  apart. 
They  came  on  as  follows;  the  eyes  would  first  deviate  to  the  right. 
The  right  side  of  the  face  began  twitching,  iDulling  the  mouth  to 
the  right.  Then  clonic  couA-ulsions  started,  first  in  the  right  arm  and 
from  here  the  whole  body  became  involved.  These  convulsions  kept 
up  for  about  two  minutes,  when  the  convulsions  became  tonic  for  about 
a  minute  with  gradual  relaxation.  The  breathing  was  stertorous 
during  the  con"^Tilsion,  the  face  becoming  cyanotic.  After  the  con- 
^Tilsion  he  broke  out  in  a  profuse  sweat.  Because  the  con^iilsions 
started  in  the  riglit  arm.  an  attempt  to  find  a  fecal  lesion  was  decided 


56 


CLINICAL    SURGERY    V.Y    CASE    HISTORIES 


on.  All  incision  was  nuule  alon<i'  tlie  line  of  liis  previous  operation. 
Tlie  tlnra  was  exposed,  and  a  needle  passed  into  the  temporal  and 
frontal  lobes.  No  pus  was  found.  The  temperature  eontinued  to 
rise  from  this  time  and  he  died  two  days  later. 

Autopsi/. — The  cranial  cavity  only  was  examined.  Necrotic  bone  in 
the  left  parietal  rc<:ion  was  found.  Pus  covered  the  frontal  lobes 
and  on  both  sides  of  the  cerebrum  and  extended  back  over  the  pa- 
rietal and  down  to  the  tem])oral  lobes  on  the  left  side.     Two  super- 


Fig.    18. — Brain  abscess   following   mastoiditis. 


ficial  abscesses  1  cm.  in  diameter  were  found  in  the  frontal  lobe  w-ell 
anterior  to  the  motor  centers.  A  larger  one  2  cm.  in  diameter  was 
located  deep  in  the  left  frontal  lobe  near  the  median  fissure  (Fig. 
18). 

Comment. — It  is  not  possible  to  calculate  the  date  wdien  the  brain 
infection  took  place.  He  probably  harbored  necrotic  bone  four  months 
after  the  mastoid  operation  was  done.  Possibly  the  removal  of  these 
might  have  prevented  the  brain  infection.  This  is  purely  a  conjec- 
ture, for  brain  abscesses  may  lie  quiet  for  indefinite  periods,  but  usu- 
ally they  do  not. 


DISEASES    OF    THE    CRAXIUM    AND    COXTENTS  57 

CASE  5. — A  machinist  aged  thirty-two  was  brought  to  the  hospi- 
tal in  an  unconscious  state. 

History. — He  had  been  at  a  neighboring'  town  attending  to  some 
business  for  several  days  previous.  He  attended  to  this  in  a  normal 
manner.  It  is  not  known  at  what  hour  he  retired  to  his  room.  The 
hotel  attendant  found  him  unconscious  at  10  o'clock  in  the  morning. 
He  was  brought  to  the  hospital  thirty-six  hours  later.  I  was  able  to 
add  to  the  history  that  his  wife  had  been  operated  on  for  pyosalpinx 
nine  months  before.     His  own  health  previously  seemed  good. 

Examination. — The  patient  is  unconscious,  the  pupils  are  unequal, 
and  react  but  feebly.  The  right  arm  is  flaccid,  while  the  left  shows 
normal  tonus.  There  are  no  marks  of  violenc?.  The  heart  and  circu- 
lation show  no  abnormalities. 

Diagnosis. — A  hemiplegia  in  a  man  of  thirty-two  without  a  source 
for  an  embolic  process  may  be  regarded  as  being  due  to  a  syj)hilitic 
thrombosis. 

Treatment. — Mercurial  injections  were  begun  at  once  and  pushed  to 
the  limit. 

After-course. — He  regained  consciousness  at  the  end  of  a  week. 
The  hemiplegia  im23roved  for  two  months  and  then  remained  station- 
ary. The  patient  admitted  that  he  had  had  a  chancre  eighteen  months 
before  and  was  cured  in  six  weeks  after  the  eruption  appeared.  He 
w^as  placed  on  potassium  iodide  which  was  increased  to  480  grains  a 
day.  This  produced  no  results  in  three  weeks,  and  the  attempt  was 
abandoned.  One  of  my  assistants  then  took  charge  and  increased  the 
dose  to  750  grains  a  day.  He  continued  this  for  three  weeks,  and  the 
motor  disturbance  entirely  disappeared.  The  jjatient  died  of  general 
paresis  five  years  later,  however. 

Comment. — At  the  present  time  one  could  give  salvarsau  to  secure 
quick  results.  But  it  should  still  be  remembered,  however,  that  the 
old  remedies  sometimes  secure  results  after  the  newer  remedy  fails. 

CASE  6. — I  was  called  to  see  a  man  aged  fifty-six  who  was  found 
unconscious  at  the  foot  of  a  stairs. 

Historij. — A  recluse  who  lived  in  a  second  story  room  was  found  at 
the  foot  of  a  stairs  at  six  in  the  morning.  Nothing  definite  is  known 
of  him,  save  that  he  prepared  his  own  meals  and  drank  alcoholics 
to  excess.  There  is  no  evidence  about  the  stairs  to  indicate  how  the 
patient  reached  the  foot  and  no  evidence  of  vomiting. 


58  CLINICAL    SURGERY    BY    CASE    HISTORIES 

Examination. — The  patient  is  a  lieavy  man  of  tiorid  complexion. 
He  lies  wholly  comatose,  the  breathing  being  slow,  deep,  and  regular, 
but  labored.  The  cheeks  puff  equally.  The  pupils  are  of  medium 
size  and  respond  feebly  to  liglit.  The  extremities  fall  heavily  when 
lifted,  being  alike  on  the  two  sides.  The  breath  carries  a  heavy  odor 
of  whiskey.  There  are  no  marks  of  injury  anywhere  on  the  body. 
There  is  no  discharge  from  the  ears  or  mouth  and  no  suggillation  about 
the  ej'es.     The  pulse  is  60,  respiration  14,  temperature  100°. 

Diagnosis. — There  is  no  evidence  of  a  fractured  skull.  Had  he  a 
skull  fracture  there  should  he  some  evidence  of  the  point  of  impact. 
Were  it  merely  a  drunk,  he  should  be  capable  of  being  aroused.  His 
habits  and  habitus  suggest  a  cerebral  hemorrhage.  There  is  no  evi- 
dence of  the  location,  since  all  extremities  seem  equally  affected 
and  both  cheeks  seem  flaccid.  By  exclusion  under  the  conditions 
which  limit  the  meaus  of  diagnosis,  apoplexy  seems  the  best  diagnosis. 

Treatment. — He  was  given  enemas  and  general  stimulation  l)y  his 
attending  physician. 

After-course. — He  was  catheterized  at  intervals  but  only  7  ounces 
of  urine  were  obtained  during  the  three  days  he  lived.  This  contained 
albumin  and  many  granular  casts.  His  hebetude  continued,  and  he 
died  three  days  after  examination. 

Autopsy. — There  is  no  fracture  of  the  skull,  and  the  brain  shows 
no  abnormalities.  There  is  congestion  at  the  base  of  both  lungs. 
The  aorta  shows  extensive  atheromatous  changes.  The  kidneys  are 
very  small,  the  surface  is  granular  and  the  capsule  closely  adherent. 
The  slides  show  extensive  interstitial  increase  and  extensive  cloudy 
swelling,  particularly  in  the  collecting  tubules. 

Cotnment. — This  patient  evidently  died  of  uremic  coma.  This  pos- 
sibility was  not  thought  of  at  the  time  of  the  original  examination. 

CASE  7. — A  young-  farmer  was  brought  to  the  hospital  because  he 
was  found  unconscious  beside  an  overturned  automobile. 

History. — The  patient  was  brought  to  the  hospital  in  an  uncon- 
scious state. 

Examination. — ^The  patient  has  an  excoriation  over  his  left  parietal 
region  and  on  his  left  shoulder.  Blood  is  escaping  from  the  ear,  and 
there  is  a  subcutaneous  induration  an  inch  above  and  anterior  to  the 
meatus.  There  is  no  bleeding  from  the  nose  or  mouth.  The  pupils 
are  equal  and  react  to  light.    The  left  loAver  lid  seems  a  little  swollen. 


DISEASES    OF    THE    CRANIUM    AND    CONTENTS  59 


Fig.    19. — Fracture   in   the   temporoparietal   region. 

There  are  no  paralyses.     The  urine  shows  some  albnniin  and  many 
epithelial  cells. 

Diagnosis. — The  escape  of  blood  from  the  external  meatus  without 
evidence  of  local  injury,  together  with  the  loss  of  consciousness,  is 
in  itself  diagnostic  of  cerebral  fracture.     The  x-ray  shows  a  fissure, 


60  CLINICAL    SrUGKRY    I'.Y    CASE    HISTORIES 

however,  exteiidin**'  ol)li(iiU'ly  ni)ward  and  backward  I'roiii  the  middle 
fossa  over  the  parietal  eminence   (Fig.  19). 

Treat moif. — The  external  ear  was  carefully  cleaned  out  with  boric 
acid  solution  and  alcohol  and  kept  plugged  with  cotton. 

After-course. — After  the  patient  regained  consciousness  he  com- 
plained of  seeing  double.  On  the  third  day  the  left  lower  lid  showed 
a  suggillation.  Cerebrospinal  fluid  drained  from  the  ear  in  large 
quantities  for  ten  days.  After  this  time  the  flow  ceased  at  intervals. 
When  the  flow  ceased,  he  complained  of  headache  and  of  feeling  bad 
in  general.  When  the  flow  would  start  again  he  was  relieved  at  once. 
When  the  flow  ceased  permanently,  he  had  a  very  severe  headache 
and  his  temperature  rose  to  103°  and  the  pulse  dropped  from  80  to 
65.    Within  a  day,  however,  the  equilibrium  was  restored  again. 

Comment. — The  puffiness  of  the  lower  lid  showed  several  days  be- 
fore the  evidence  of  deep  h(>morrhage  appeared.  In  the  absence  of 
hemorrhage  from  the  ear  and  before  an  x-ray  can  be  had  this  evi- 
dence is  worth  looking  for.  It  means  a  deep  hemorrhage  which  has 
not  yet  had  time  to  reach  the  surface.  The  significance  of  orbital 
suggillation  appearing  several  days  after  a  cranial  injury  is  well 
recognized.  The  swelling  above  noted  anticipates  its  appearance. 
The  temporary  headache  and  rise  in  temperature  evidently  were 
due  to  an  increase  of  intracranial  pressure,  as  indicated  by  the  fall 
in  the  pulse  rate. 

CASE  9. — A  farmer  aged  forty-six  was  brought  to  the  hospital 
because  of  headaches,  inability  to  speak,  and  partial  paralysis. 

Ilistorij. — The  patient  dates  the  beginning  of  his  trouble,  according 
to  a  relative,  from  sunstroke  six  years  ago.  The  first  evidence  of  his 
trouble  came  one  morning  while  seated  at  the  breakfast  table ;  he  had 
a  feeling  of  excitement  and  instinctively  ran  to  the  door  for  air. 
While  in  this  state  he  made  several  unsuccessful  efforts  to  speak. 
The  attack  lasted  only  a  few  minutes  and  he  is  not  sure  whether  he 
lost  consciousness  or  not.  He  was  able  to  walk  in  an  hour,  and 
continued  with  his  farm  work.  He  had  a  similar  spell  six  months 
later.  Since  then  they  have  increased  in  frecpiency.  During  a  spell 
two  years  ago  there  was  weakness  in  the  right  arm  and  shoulder, 
and  a  year  later  the  leg  was  affected.  In  the  past  two  years  all  these 
symptoms  have  increased.  He  has  had  severe  occipital  headache  re- 
cently, although  he  has  had  some  for  sixteen  years. 


DISEASES    OF    THE    CRANIUM    AND    CONTENTS  61 

Examination. — The  patient  is  bedridden  and  can  not  lift  his  right 
arm.  Poor  power  in  right  leg.  Frontal  lobe  asthenia.  Left  side 
deep  reflexes  present,  mild  Babinski.  Right  brisker  than  left,  but 
no  clonus.  Marked  right  Babinski.  Movements  of  defense  increased 
on  right.  Left  abdominal  brisk,  right  absent.  Right  cremasteric 
brisker  than  left.  Sensation  could  not  be  tested  well  on  account  of 
mental  state.  Sphincteric  control  impaired.  Hearing  probably  nor- 
mal, right  facial  paralysis.  Ophthalmoscopic  examination  showed 
slight  blurring  of  discs,  retinal  vessels  congested.  Did  not  talk,  ex- 
cept to  say  ''yes"  and  "no."  Obeyed  commands  and  apparently 
understood  everything.  Cried  and  showed  other  evidence  of  emotional 
disturbance.  Spinal  pressure  360  mm.  which  fell  to  180  after  33  c.c. 
were  removed.     Cell  count  1.2.  Wassermann  and  gold  negative. 

Diagnosis. — The  nature  of  the  motor  disturbances  makes  the  loca- 
tion in  the  Rolandic  region  certain.  Its  relation  to  a  sunstroke  seems 
unlikely.  As  a  matter  of  fact  the  alleged  sunstroke  likely  was  the 
earliest  manifestation  of  the  disease.  The  apparently  sudden  onset 
b}^  no  means  indicates  a  sudden  origin  of  the  lesion. 

Treatment. — A  large  bone  flap  was  turned  down,  exposing  the  pre- 
Rolandic  region.  There  was  apparently  a  marked  increase  of  intra- 
cranial pressure  at  the  site  of  operation  and  the  pial  vessels  were 
much  congested.  A  large  needle  was  introduced  at  the  central  point 
and  at  a  depth  of  half  an  inch  a  clear  straw-colored  fluid  was  obtained. 
In  all  250  c.c.  were  removed. 

After-course. — Three  weeks  after  operation  he  returned  home.  He 
walked  with  only  a  little  limp.  His  speech  was  good,  being  only 
a  little  slow.  Reflexes  about  normal,  right  slightly  greater.  Babinski 
gone.  Abdominal  and  cremasteric  equal.  Sensory  normal.  Coor- 
dination good.  Eye  grounds  improved.  This  improved  state  con- 
tinued nine  months.  After  this  he  began  to  have  convulsions  with 
unconscious  periods.  These  became  worse  and  a  year  after  the  opera- 
tion 55  c.c.  of  fluid  were  aspirated  through  trephine  opening.  Prompt 
improvement  followed.  This  procedure  was  repeated  several  times 
during  the  following  year.  Two  3'ears  after  the  first  operation  the 
cyst  was  opened  and  packed  with  gauze.  Instead  of  improving  the 
state  the  attempts  at  obliteration  seemed  to  stimulate  secretion,  for 
the  cyst  filled  more  rapidly  and  there  was  less  marked  improvement 
after  the  aspirations  were  done. 


62 


rLIXICAL    SURGERV    BY    CASE    HISTORIES 


Commeni. — It  is  not  possible  to  state  the  nature  and  origin  of  this 
cyst.  There  Avas  nothing  in  the  fluid  first  removed  to  indicate  that 
a  hemorrhage  liad  preceded  it.  The  development  seems  to  be  too 
slow  to  lie  a  degenerative  developing  in  the  interior  of  the  tumor. 

CASE  10. — A  farmer  aged  fifty-six  came  to  the  hospital  because 
of  headache  and  a  tumor  on  his  head. 

Jlistory. — Two  years  ago  while  fixing  machinery  a  small  bit  of  steel 


Fig.  30.^ — A  psaniiiioiiia  of  the  dura  producing  a  tumor  in  the   parietal    region. 


penetrated  his  eye.  Pain  followed  and  he  was  treated  many  weeks 
by  an  oculist.  One  year  age  he  noticed  a  lump  appearing  on  the  top 
of  his  head.  About  the  same  time  he  began  to  have  spells,  when  his 
speech  would  become  thick.  Headaches  began  to  develop  soon  after 
the  eye  injury,  and  have  persisted  until  the  present  time.  These 
have  been  particularly  severe  during  the  past  six  months.  There  has 
been  no  nausea  or  vomiting.  Now  the  speech  is  indistinct  at  all 
times  and  his  mental  processes  are  much   impaired.     For  the  past 


DISEASES    OF    THE    CRAXIUM    AND    COXTEXTS  63 

three  months  his  gait  has  been  affected.     He  is  particularly  likely 
to  stumble  with  the  left  foot. 

Examination. — Over  the  parietal  region,  directly  above  the  ear  and 
midway  between  the  ear  and  the  midline,  is  an  ovoid  tumor,  extend- 
ing outward  half  an  inch  or  more  is  a  smooth,  globular  tumor  (Fig. 
20).  The  skin  moves  over  it.  but  it  seems  a  part  of  the  skull.  It  is 
smooth,  hard,  and  painless.  There  is  a  general  impairment  of  the 
motor  system  most  marked  on  the  left  side.  There  is  no  ataxia  or 
Romberg.  The  right  eye,  the  injured  one,  has  a  cataract.  The  pu- 
pillary reflex  is  gone.     The  left  eye  responds  to  light  and  the  disc 


■hi 


-^  <e^-'  ■'•'^?^ 


Fig.    21. — Slide    of   a   brain   tumor   showing    a   psammoma. 

shows  cupping.     The  spinal  fluid  pressure  is  370  mm.,  AYassermann 
negative,  Bp.  130. 

Diagnosis. — The  presence  of  a  tumor  in  the  parietal  region  as  above 
noted  with  motor  impairment  of  the  opposite  side  suggests  a  tumor 
of  the  skull.  Since  tumors  arising  in  the  diploe  tend  to  extend  as 
much  or  more  into  the  cranial  cavity  as  they  do  beyond  the  surface, 
this  seems  the  probable  diagnosis.  These  tumors,  when  primary,  are 
usually  sarcomas.  AMien  metastatic  they  are  adrenal  or  thyroid. 
There  is  no  evidence  of  a  tumor  elsewhere,  and  this  must,  because  of 
this  lack,  be  regarded  as  primary.  The  eye  signs  and  the  result  of 
the  spinal  puncture  indicate  an  increased  intracranial  pressure.  There 
is  no  evidence  that  the  eye  injury  bears  any  relation  to  the  present 


04  CTJXicAi,  sriu;i;RY  by  case  htstoktks 

trouble.  Were  it  not  for  tlie  tumor  externally  visible  a  chronic  ab- 
scess might  be  considered.  Considering  the  evidence  at  hand,  a  pri- 
mary sarcoma  of  the  skull  seems  to  be  the  best  diagnosis.  Such  tumors 
have  been  successfully  removed. 

Treaiment. — The  tumor  mass  was  circumscribed  with  a  Dahlgren 
forceps.  Instead  of  finding  a  tumor  protruding  into  the  cranial  cav- 
ity the  tumor  appearing  externally  proved  to  be  merely  a  shell  the 
bulk  of  the  visible  mass  being  made  up  of  soft  granular  material. 
When  the  disc  of  bone  was  romioved  there  was  a  large  mass  of  this 
soft  material  apparent.  It  was  brownish  red  and  within  it  were 
many  small  granules  giving  the  feeling  of  soft,  finely  mixed  cement. 
This  extended  below  the  surface  of  the  brain  half  an  inch.  The  bor- 
ders were  ill-defined  and  all  the  tumor  substanci'  could  not  be  re- 
moved. 

PdfJioIofjy. — The  slide  shows  a  cellular  nuitei'ial  with  a  s-.nall  amount 
of  connective  tissue.  Here  and  there  are  concentric  masses  which 
stain  deeply  with  acid  dyes.  These  are  evidently  psammoma  bodies 
and  the  tumor  therefore  a  psammoma  (Fig.  21). 

After-course. — The  })atient  improved  for  a  few  months,  so  far  as 
the  headaches  were  concerned.  After  this  the  general  impairment 
resulted  in  his  death  a  few  months  later. 

Comment. — It  is  (juite  unusual  for  tumors  of  this  kind  to  produce 
a  mass  visible  externally.  In  this  case  apparenth'  the  bone  became 
involved  and  the  tumor  visible  was  the  result  of  newly  formed  bone 
which  attempted  to  bridge  the  impending  defect.  Psammonias  being 
diffuse  in  character  are  never  operable. 


CHAPTER  III 

DISEASES  OF  THE  FACE  AND  ACCESSOEY  SINUSES 

That  portion  of  the  head  which  is  not  cranium  and  does  not  belong 
to  the  masticatory  apparatus  ma}"  be  regarded  as  face.  The  lips  are 
excluded  because  the  covering  mucous  membrane  causes  them  to  align 
in  their  clinical  behavior  with  the  interior  of  the  buccal  cavity.  The 
usual  affections  that  come  to  surgeons  are  either  neoplastic,  inflamma- 
tory or  neuralgic.  A  tumor  may  be  inflammator}"  and  hence  painful, 
then  painful  because  inflammatory.  When  a  tumor  is  not  painful  it 
is  neoplastic  and  when  there  is  pain  without  augmentation  in  volume 
it  is  neurologic.  Since  the  diseases  in  this  region  serve  as  the  ccmmon 
meeting  ground  of  half  the  specialists  in  medicine,  self-defense  de- 
mands of  the  general  surgeon  a  detailed  knowledge  of  the  diseases  of 
this  region. 

PAINFUL  AFFECTIONS  OF  THE  FACE 

The  common  painful  affection  of  the  face  of  surgical  importance 
is  tic  douloureux.  The  intermittenee  and  the  lancinating  character  of 
the  pains  are  wholly  characteristic.  Notwithstanding  this,  patients 
are  commonly  subjected  to  unnecessary  mutilations,  of  which  extrac- 
tion of  teeth  and  enucleation  of  an  eye  are  the  most  common.  For- 
merly the  teeth  were  extracted  because  they  were  regarded  as  the 
source  of  the  pain ;  now  they  are  removed  because  they  are  suspected 
of  harboring  foci  of  infection  which  are  indirectly  believed  to  cause 
the  neuralgia.  It  is  an  unwarranted  procedure  in  either  theory. 
Eyes  are  removed  because  the  neuralgia  is  mistaken  for  a  glaucoma. 

CASE  1.— A  carpenter  aged  fifty-four  came  to  the  hospital  be- 
cause of  paroxysmal  pains  in  the  face  and  jaw. 

History. — Beginning  eighteen  years  ago  he  noticed  lancinating  pains 
in  the  right  cheek  when  exposed  to  cold  blasts  of  air.  These  attacks 
recurred  at  infrequent  intervals  only,  in  the  beginning.  After  sev- 
eral years  the  attacks  came  closer  together  and  were  excited  by 
a  variety  of  stimuli,  particularly  draughts  of  cold  air  and  by  light 

65 


66  rUXlCAL   SURGERY   BY    CASE   HISTORIES 

stroking  of  the  face.  Eating  did  not  excite  the  attacks  unless  the 
food  was  cold.  After  eight  years  a  peripheral  operation  was  done, 
removing  the  third  branch.  Relief  for  a  year  and  a  half  followed. 
At  the  lapse  of  this  time  the  pains  returned,  reaching  their  original 
intensity  five  years  ago,  when  the  second  peripheral  operation  was 
done.  The  relief  this  time  was  less  than  a  year,  and  one  year  ago 
a  third  peripheral  operation  was  done.  No  relief  at  all  followed  this 
operation,  and  the  pains  increased  in  intensity,  coming  on  in  violent 
paroxysms,  apparently  without  cause.  At  this  time  the  movements 
incident  to  mastication  excited  attacks. 

Examination. — Large,  powerful  man,  not  appreciabh'  emaciated, 
but  bearing  the  facial  expression  of  intense  suffering.  An  attempt 
to  determine  the  nerve  chietly  involved  brought  on  paroxysms  by 
the  slightest  touch.  Obviously  the  second  and  third  branches  were 
involved,  the  lingual  probably  least  of  all.  Because  of  the  intense 
sulfering,  the  nerves  were  blocked  at  the  infraorbital  and  mental 
foramina  with  quinine.  This  was  done  to  give  temporary  relief 
while  operation  was  being  arranged  for  and  to  permit  an  examination 
of  the  lingual  branch.  This  gave  complete  relief,  which  likely  would 
not  have  been  the  case  if  the  lingual  nerve  had  been  involved.  As  a 
matter  of  fact  tliis  seems  to  be  universally  the  case,  so  that  I  am  skep- 
tical about  the  primary  involvement  of  this  branch. 

Treatment. — A  typical  Krause  operation  was  done.  The  patient 
left  the  hospital  in  a  week. 

After-course. — After  awaking  from  the  anesthetic  he  occupied  his 
time  by  singing  religious  songs.  It  was  thought  that  he  had  suffered 
a  mental  aberration  from  the  operation.  He  explained,  however,  that 
when  he  regained  consciousness  and  discovered  that  he  was  free  from 
pain,  his  joy  was  so  great  that  he  burst  into  song.  His  efforts  bore 
evidence  that  musical  excellence  is  not  necessary  to  the  expression  of 
joy.    He  has  remained  free  from  pain,  now  ten  years. 

Comment. — The  fact  that  he  received  no  relief  from  the  last  periph- 
eral operation  must  be  explained  by  assuming  that  the  nerve  was 
not  found.  The  large  amount  of  fibrous  tissue  resulting  from  pre- 
vious operations  makes  such  an  error  easy.  When  recurrence  follows 
a  peripheral  operation,  it  is  unwise  to  attempt  another. 


DISEASES   OF    THE   FACE   AND    ACCESSORY    SINUSES  67 

CASE  2. — A  merchant  aged  fifty -three  came  in  for  relief  of  pain 
in  the  left  side  of  his  head  and  face. 

History. — For  years  he  has  had  spells  of  pain  in  the  left  side  of  his 
head  and  face.  He  tried  all  the  usual  remedies  with  no  improvement. 
Finally  he  had  an  x-ray  examination  made  of  his  teeth.  He  was  ad- 
vised to  have  some  of  them  extracted.  This  was  done,  with  relief 
for  a  time.  Later  he  had  all  the  remaining  teeth  extracted.  He  then 
had  no  trouble  for  several  months,  but  the  pain  came  back.  Recently 
the  pain  was  so  severe  that  he  had  to  go  to  bed.  He  had  the  nerves 
injected  with  alcohol  at  this  time.  This  relieved  the  pain  until  the 
operation  was  done. 

Examination. — There  is  anesthesia  on  the  left  side  of  the  face  from 
previous  alcohol  injections.  Blood  pressure  110.  Heart  and  lungs 
negative.  The  patient  has  lost  about  30  pounds  of  weight  but  other- 
wise seems  in  good  health.  Xeural  examination  was  negative,  save 
that  the  cell  count  of  the  spinal  fluid  was  somewhat  increased. 

Diagnosis. — As  in  most  of  these  cases,  the  patient  brought  the  diag- 
nosis with  him. 

Treatment. — The  preliminary  steps  of  the  operation  were  done  un- 
der local  anesthesia.  The  lifting  of  the  dura  from  the  ganglion  and 
nerve  root  proved  2)ainful,  and  ether  was  given.  The  sensory  root 
was  severed  with  a  fine  electric  cautery.  It  was  interesting  to  note 
that  the  perfectly  dry  field  that  was  secured  while  working  with  local 
anesthesia  burst  into  a  multitude  of  small  oozing  points  when  the 
patient  was  under  the  influence  of  ether.  This  demonstrates  well  the 
greater  disposition  to  bleed  when  the  general  anesthetic  is  given. 

After-course. — He  had  considerable  headache  on  the  left  side  fol- 
lowing the  operation.  This  was  still  present  when  the  patient  left 
the  hospital,  but  subsided  in  a  few  weeks  following.  He  soon  regained 
his  lost  weight. 

Comment. — -Despite  the  fact  that  he  consulted  competent  men  the 
teeth  were  needlessly  sacrificed.  No  infected  foci  were  demonstrated 
about  their  roots.  Tic  is  a  remittent  disorder  and  a  therapeutic 
measure  may  erroneously  be  credited  with  producing  the  free  in- 
terval. This  operation  will  never  reach  the  ideal  state  until  some 
method  is  discovered  whereby  the  nerve  can  be  exposed  painlessly 
under  local  anesthesia.  The  cautery  lessens  the  hemorrhage  in  the 
final  step  of  the  operation.  The  cautery  point  must  be  fine  so 
that  the  degree  of  heat  obtained  will  not  injure  surrounding  tissue. 


68  (  iJXK  Ai.  >rii(.i:KV  i;v  (  ask  histokii> 

CASE  3. — A  farmer  aged  sixty-three  entered  the  hospital  because 
of  pain  in  the  right  side  of  his  face. 

History. — The  patient  has  had  spasmodic  pains  in  the  right  side  of 
his  face  for  nearly  thirty  years.  He  was  operated  on  for  the  re- 
moval of  the  nerves  sixteen  years  ago,  but  without  even  temporary 
results.  He  was  bedfast  for  two  and  a  half  years  because  when  he  got 
up  the  paroxysms  increased  in  number  and  frequency.  The  paroxysms 
came  on  every  30  to  60  minutes.  The  pains  begin  at  the  angle  of 
the  jaw  and  shoot  into  the  side  of  the  head.  The  left  side  of  the  face 
has  been  painful  every  four  or  five  weeks  for  a  year.  The  pains  on 
this  side  remain  localized  in  the  jaM-.  He  is  taking  32  grains  of  mor- 
phine a  day. 

Examination. — He  bears  the  scar  of  the  operation  of  sixteen  years 
ago.     Examination  is  impossible  because  of  the  pain  excited. 

Di<ignosis. — Trigeminal  neuralgia. 

Treatment. — The  ganglion  was  removed  under  local  anesthesia.  The 
operation  was  quite  painless  until  the  dura  about  the  ganglion  was 
l)eing  elevated.  As  soon  as  the  ganglion  was  located  an  injection  was 
made  into  it.  This  promptly  produced  vomiting,  but  the  operation 
was  then  completed  without  discomfort  to  the  patient. 

After-course. — Relief  from  j^ain  was  immediate  and  permanent.  He 
returned  six  months  later  for  relief  for  the  other  side.  A  peripheral 
operation  was  done,  removing  the  2nd  and  3rd  branches.  He  was 
free  from  pain  for  two  years,  when  it  gradually  returned.  Three 
years  after  the  first  radical  operation  he  returned  for  a  radical  opera- 
tion on  the  left  side.  This  was  done  under  ether.  The  hemorrhage 
was  so  great  before  the  ganglion  was  effectuallj-  exposed  that  packing 
had  to  be  resorted  to.  Four  days  later  the  packing  was  removed 
and  the  ganglion  exposed  and  attacked.  This  plan  lessens  the  amount 
of  hemorrhage  considerably.  The  technic  was  modified  to  the  extent 
that  the  sensory  root  was  exposed  and  destroyed  by  a  fine  cauterj'  at 
low  heat.  During  the  interval  between  the  two  operations  while  the 
pack  was  in  place,  he  suffered  much  pain  and  had  some  mental  aberra- 
tion. I  have  used  the  cautery  half  a  dozen  times  and  the  results 
seem  to  be  satisfactory-. 

Comment. — It  is  always  a  misfortune  when  the  operator  is  obliged 
to  do  the  operation  in  two  stages.  It  is  probably  a  confession  of  too 
bungling  operating.  It  is  much  better  to  do  the  operation  in  two 
stages,  however,  than  to  persist  when  hope  of  an  effectual  exposure 


DISEASES    OF    THE    FACE    AND    ACCESSORY    SINUSES  69 

is  passed.  Having  had  the  unique  experience  of  having  one  side  op- 
erated on  under  local  anesthesia  and  the  other  under  general,  it 
seemed  this  patient's  opinion  relative  to  the  methods  of  anesthesia 
should  be  worth  something.  He  expressed  himself  as  being  emphati- 
cally in  favor  of  local  anesthesia.  This  preference  may  have  been 
due,  however,  to  the  fact  that  he  was  packed  after  the  second  opera- 
tion. Local  anesthesia  has  the  advantage  of  lessening  materially  the 
difficulties  in  technic  because  of  the  reduced  hemorrhage.  Cases 
where  the  operation  is  done  under  local  anesthesia  to  the  point  where 
the  ganglion  is  to  be  exposed  and  then  ether  is  given  illustrate  this 
very  well.  A  wound  that  is  perfectly  dry  bleeds  at  myriad  j)oints 
upon  giving  the  patient  ether.  There  seems  to  be  no  way  of  control- 
ling the  pain  of  separating  the  dura  from  the  base  of  the  skull,  how- 
ever; theoretically  the  ganglion  should  be  injected  through  the  fora- 
men ovale  before  the  operation  is  begun.  Practically  this  can  not 
always  be  done.  In  the  cadavers  it  is  easy,  but  on  the  living  it  is  an- 
other matter. 

CASE  4. — A  stockman  aged  sixty-four  entered  the  hospital  com- 
plaining of  attacks  of  acute  pain  in  the  right  side  of  his  face. 

History. — The  patient  has  never  been  sick  since  childhood.  He 
does  not  and  never  has  used  tobacco  or  alcohol.  The  present  trouble 
started  six  years  ago  with  occasional  twinges  of  pain  in  the  right 
side  of  the  nose.  At  first  the  attacks  of  pain  were  not  so  severe,  but 
they  grew  steadily  more  and  more  frequent.  In  the  past  two  months 
it  has  been  especially  bad.  The  pains  are  of  a  spasmodic,  jerky, 
lightning-like  character.  The  paroxysm  is  brought  on  b.y  brushing 
the  side  of  the  face  against  something  as  by  taking  anything  into 
the  moutb.  The  pains  are  now  above  the  right  eye,  in  the  right 
eyeball,  along  the  right  side  of  the  nose,  and  when  very  severe,  it  is 
felt  over  the  malar  bone  and  in  the  upper  canine  teeth.  His  attacks 
seem  to  be  getting  worse  all  the  time.  They  come  on  of  late  as  often 
as  every  15  minutes,  day  and  night.  The  pain  is  also  felt  now  in  the 
right  occipital  region  and  extends  to  the  top  of  the  head.  His  gen- 
eral health  is  excellent.  He  has  no  other  trouble.  Appetite  good, 
bowels  regular,  no  urinary  disturbance. 

Examination. — Blood  pressure  150-90.  Head  and  neck  negative  ex- 
cept that  touching  the  side  of  the  face  starts  paroxysm  of  pain.  Heart 
and  lungs  negative.    Abdomen  negative. 


70 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


Diagnosis. — Trifacial  neuritis  iuvolviug  the  1st  and  2nd  l)ranches. 

Treatment. — The  supraorbital  and  infraorbital  nerves  of  the  1st 
and  2nd  division  of  the  5th  injected  with  grain  alcohol.  The  technic 
of  the  operation  is  simple,  yet  it  requires  a  certain  amount  of  care. 
By  preceding  the  injection  of  alcohol  with  novocaine  the  operation 


Fig.    22. — Direction    in    which    the    needle    must    approach    the    foramen    in    order    to    enter    it 

properly. 


can  be  done  with  but  very  little  pain.  The  first  branch  is  the  most 
difficult  to  inject,  unless  the  nerve  can  be  located  by  the  pressure 
pain  or  a  palpable  notch  is  present.  It  must  be  remembered  also 
that  the  nerve  may  appear  as  two  divisions.  The  second  branch 
is  more  easily  found  (Fig.  22).  It  is  usually  a  bare  fiugerbreadth 
lateral  to  the  nose.    Bv  entering  the  needle  a  fiugerbreadth  below 


DISEASES    OF    THE   FACE    AND    ACCESSORY    SINUSES  71 

the  lower  border  of  the  orbit,  the  needle  can  be  passed  into  the 
foramen  usually  half  an  inch  or  more.  Care  mnst  be  exercised 
not  to  force  it  through  the  thin  plate  of  bone  in  the  floor  of  the 
orbit  and  so  make  the  injection  in  the  loose  orbital  tissue.  With 
care  the  needle  can  be  made  to  enter  the  foramen.  Once  the  needle 
is  entered,  a  few  drops  of  novocaine  are  injected  and  after  a  few 
minutes  the  alcohol  is  injected.  The  needle  may  be  left  in  the 
foramen  during-  this  interval.  Instead  of  using  a  diluted  alcohol 
I  allow  the  novocain  solution  to  act  as  the  dilutant  injecting  say 
5  drops  of  novocaine  solution  and  follow  this  with  15  or  20  drops  of 
standard  grain  alcohol.  The  mental  foramen  is  found  below  the 
base  of  the  canine  tooth.  By  stepping  along  with  the  needle  it  can 
usually  be  located.  If  not,  the  injection  can  be  made  about  where 
it  should  be.  I  have  never  failed  to  secure  good  results  even  when 
the  foramen  was  not  exactly  located.  I  tried  injecting  the  lingual 
branch  opposite  the  lingula  just  once.  The  reaction  in  the  masse- 
ter  muscle  produced  a  fibrosis  which  made  it  impossible  for  the 
patient  to  open  her  mouth  more  than  half  an  inch.  This  is  quite 
enough  to  enable  her  to  express  her  opinion  of  the  method. 

After-course. — "Within  twenty-four  hours  after  injection,  the 
right  eye  was  swollen  shut  owing  to  irritation  of  the  alcohol  on  the 
soft  tissues.  The  swelling  was  practically  gone  in  three  days,  but  he 
still  had  paroxysms  of  shooting  pain  along  the  side  of  the  nose,  in  the 
right  eyeball,  at  the  inner  angle  of  the  eye,  and  along  the  supraorbital 
ridge  towards  the  outer  side  of  the  eye.  The  pain  was  still  present, 
but  diminishing  in  severity  when  he  left  the  hospital  at  the  end  of 
a  week.     Within  a  few  days,  however,  all  pain  ceased. 

Comment. — The  injections  of  the  nerves  at  the  foramen  give  as 
prompt  and  as  permanent  relief  as  does  injection  at  the  foramen 
ovale. 

CASE  5. — This  man  was  brought  to  the  hospital  when  sixty- 
eight  years  of  age  because  of  severe  pains  in  the  right  side  of  the 
face. 

History. — The  patient  has  had  paroxysmal  attacks  at  intervals  for 
some  fifteen  years.  At  first  they  were  severe  in  the  spring  and  fall 
onlj^  In  1908  he  had  the  nerves  injected  at  the  foramen  by  an  ex- 
pert at  this  art.  Relief  from  symptoms  followed,  but  the  cornea 
became  ulcerated  and  the  sight  of  the  eye  was  lost.    The  freedom  from 


72  CLINICAL   SURGERY    BY    CASE    HISTORIES 

pain  lasted  eighteen  months.  Following  this  he  had  a  severe  attack 
dnring  the  spring,  lasting  several  weeks.  During  the  snmmer  he  was 
fairly  free,  bnt  now  two  years  and  a  half  following  he  has  had  nearly 
constantly  recnrring  attacks  every  three  weeks.  Swallowing  brings 
on  violent  spasms  of  pain. 

Examination. — The  point  most  sensitive  to  touch  is  just  below  the 
infraorbital  foramen,  but  stroking  the  lip  brings  on  the  paroxysms 
which  involve  also  the  nerves  of  the  lower  jaw.  The  patient  has 
a  dilated  heart,  the  apex  being  well  beyond  the  nipple  line.  It  is 
irregular  in  rate  and  volume.  The  urine  is  of  low  specific  gravity 
and  contains  a  few  hyaline  casts.  His  lungs  are  generally  emphy- 
sematous. 

Diagnosis. — In  this,  as  in  most  cases,  the  patient  comes  to  the  sur- 
geon with  the  diagnosis  alread}^  made.  Usually  also  he  has  run  the 
gamut  of  injection  treatment  and  he  is  prepared  to  listen  to  propos- 
als of  radical  measures.  The  surgeon's  task,  therefore,  is  to  diagnose 
the  patient  rather  than  the  disease,  to  determine  the  kind  of  operation 
advisable. 

Treatment. — Because  of  the  patient's  unfavorable  condition,  a  rad- 
ical operation  was  not  proposed.  A  peripheral  resection  of  the  nerves 
was  undertaken.  In  order  to  lessen  the  duration  of  anesthesia  the 
second  branch  was  removed  under  local  anesthesia  and  the  third 
branch  under  ether. 

After-course. — The  patient  remained  free  frcm  pain  for  a  year  and 
a  half.  After  this  time  the  pain  returned  to  nearly  its  former  in- 
tensity. Alcohol  injections  were  made  into  the  infraorbital  and  men- 
tal foramina.  Relief  for  six  months  followed.  Renewed  pains  and 
renewed  injections  at  the  same  site  followed  at  intervals  of  six 
months  to  a  year  for  now  six  years.  By  this  means  he  was  kept 
comfortable.  He  has  now  be?n  free  for  a  year  and  a  half  since  the 
last  injection. 

Comment. — Because  of  his  general  condition  the  peripheral  opera- 
tion was  chosen  instead  of  the  removal  of  the  ganglia.  It  appeared 
as  though  he  would  succumb  from  other  causes  during  the  usual 
period  of  immunity  from  a  peripheral  operation.  The  peripheral 
injection  was  done  the  first  time  because  no  needle  suitable  for  a 
deep  injection  was  available.  The  results  were  so  satisfactory  that 
the  same  method  was  pursued  at  subsequent  sittings.     I  have  had 


DISEASES    OF    THE   FACE   AND    ACCESSORY   SINUSES  73 

occasion  to  employ  the  same  teclinic  with  other  patients  with  equally 
good  results.  This  method  has  the  advantage  in  that  it  can  be  done 
with  an  ordinary  hypodermic  syringe  by  any  one,  while  the  deep 
injection  requires  some  special  skill  and  a  special  needle. 

CASE  6. — A  matron  aged  fifty-seven  came  to  the  hospital  because 
of  paroxysmal  pains  in  the  right  cheek. 

Histonj. — Six  months  ago  while  washing  her  face  the  patient  had 
a  sudden  paroxysm  of  pain  in  the  right  cheek.  This  pain  has  re- 
curred at  intervals  since  that  time,  and  for  the  past  month  they 
have  been  nearly  constant,  requiring  opiates  for  their  relief.  The 
general  health  of  the  patient  has  always  been  good. 

Diagnosis.- — The  upper  lip  and  cheek  on  the  right  side  are  very 
sensitive  to  touch.  There  is  marked  tenderness  over  the  infraorbital 
foramina.  There  is  no  involvement  of  the  third  branch.  The  rou- 
tine examination  of  the  hospital  gave  a  blood  pressure  of  210,  with 
normal  urine. 

Treatment. — The  second  branch  was  removed  under  local  anesthe- 
sia. 

After-course. — While  the  patient  was  lying  in  bed  she  discovered 
that  there  was  some  defect  in  vision.  Certain  areas  in  the  fi'^ld  of 
vision  seemed  to  be  disturbed.  Some  parts  of  the  wallpaper  seemed 
to  be  blotted  out,  as  it  were.  Since  anesthesia  of  the  optic  nerve  some- 
times follows  this  operation  it  was  thought  that  possibly  the  disturb- 
ance was  due  to  the  local  anesthesia.  "When  it  did  not  clear  up  in  a  day 
an  oculist  was  consulted.  He  found  multiple  retinal  hemorrhages  which 
he  estimated  to  be  from  two  to  four  weeks  old.  Fortunately  the  op- 
posite eye  was  similarly  affected.  She  had  a  blood  pressure  of  240 
at  this  time,  and  the  urine  contained  some  albumin  and  a  few 
casts.  Notwithstanding  that  it  was  pretty  certain  that  the  de- 
fect existed  before  the  operation,  the  patient  was  not  fully  convinced. 
She  was  permanently^  relieved  of  the  pain,  however. 

Comment. — The  embarrassment  due  to  the  disturbance  of  the  eye 
might  have  been  saved  had  the  eyes  been  examined  before  the  opera- 
tion. Usually  patients  are  grateful  to  be  relieved  from  their  trouble 
and  do  not  complain  of  minor  disturbances  even  when  due  to  the 
operation. 


74 


CLIXICAL    SURGERY    BY    CASE    HISTORIES 


CASE  7. — A  housewife  aged  sixty-two  came  to  the  hospital  be- 
cause of  neuralgia  in  the  right  side  of  her  face. 

History. — Attacks  come  on  without  warning,  very  suddenly,  with 
severe  pain  along  the  lower  jaw  and  at  times  across  the  cheek  and  up 
along  the  side  of  the  nose  to  the  inner  side  of  the  eye.  It  is  sometimes 
a  hurning,  jerking  sensation,  at  other  times  a  twitching,  cutting 
pain.  Attacks  usually  last  about  five  minutes.  They  subside  as 
quickly  as  they  bogin.     f^he  had  srme  pain  like  this  for  about  twenty 


Fig.  23. — By  passing  iln  i.^^d!^  jlIs;  i,,  iiui.i  ui  il.e  condyle  of  tlie  lower  jaw  and  con- 
tinuing inward  until  it  strikes  the  pterygoid  plate,  the  point  will  lodge  just  in  front  of  the 
foramen.     By  redirecting  the  needle  a  little  more  backw'ard  the  nerve  can  be  reached. 

years.  Has  been  much  worse  fur  the  past  five  years.  Her  surgeon 
injected  the  infraorbital  nerve  with  alcohol  about  seven  years  ago. 
This  gave  relief  for  about  one  year.  During  the  last  year  the  patient 
has  had  attacks  every  few  days  to  a  few  weeks  apart. 

Examination. — Heart  action  slightly  lowered,  probably  due  to  nar- 
cotics. Skin  yellow  tinged.  Very  few  signs  of  arteriosclerosis.  Blood 
pressure  130-80.  Sensation  more  acute  over  whole  right  side  of  the 
face.     Touching  face  Avitli  a  pini)oint  did  not  start  paroxysm. 


DISEASES    OF    THE   FACE   AND   ACCESSORY    SINUSES  75 

Diagnosis. — As  is  usual  with  these  patieuts  she  seeks  relief,  not  a 
diagnosis. 

Treatment. — The  second  and  third  branches  were  injected  with 
alcohol  at  the  foramen  ovale.  The  technic  employed  was  as  follows: 
midway  of  the  zygomatic  arch  at  its  lower  border  a  needle  is  passed 
directly  inward  until  the  pterygoid  process  is  encountered.  This  is 
usually  from  -1  to  5  cm.  below  the  skin  surface.  The  needle  is  then 
withdrawn  until  the  point  is  just  beneatli  the  skin.  It  is  then  intro- 
duced a  like  depth  in  a  direction  along  a  line  from  the  point  of  en- 
trance to  a  point  2  cm.  above  the  mastoid  process  on  the  other  side 
or  the  needle  may  be  entered  just  in  front  of  the  condyle  of  the 
lower  jaw  and  passed  obliquely  inward,  upward,  and  forward  until 
the  foramen  is  reached  (Fig.  23).  Here  a  few  minims  of  novo- 
caine  solution  are  injected  and  after  an  interval  of  five  minutes  the 
alcohol  is  injected.  In  order  to  mark  the  point  on  the  needle  when  the 
pterygoid  process  is  touched  a  cork  disc  may  be  placed  on  the  needle 
or  a  small  forcep  may  be  clamped  on  it,  or  if  the  needle  is  near  the 
right  length,  one  can  mark  the  point  with  his  eye.  If  the  patient  com- 
plains of  shooting  pains  in  the  jaw,  one  may  know  the  right  point  has 
been  reached. 

After-course. — The  patient  remained  free  from  pain  for  nearly  two 
years.  The  pains  became  more  intense  than  before  and  the  ganglion 
was  removed. 

Comment. — It  is  ever  thus.  There  is  but  one  cure  and  that  is  the 
removal  of  the  ganglion. 

CASE  8. — A  man  ag-ed  fifty-six  came  to  the  hospital  because  of 
a  needle-like  pricking  in  the  right  side  of  his  face. 

History. — Ten  months  ago  he  began  to  have  sharp  shooting  pains 
over  the  right  eye.  He  had  a  bad  cold  during  this  time.  Three  daj'S 
later  an  erj^sipelas  began  in  this  region.  This  was  attended  by  a 
swelling  of  the  tissues  about  the  eyes  and  rapid  pulse  and  fever. 
This  lasted  five  to  six  days.  Following  this  scabs  formed  in  this 
region  and  lasted  three  or  four  weeks.  Since  then  he  has  had  al- 
most constant  severe  burning  pain  with  occasional  sharp  shooting 
pains  in  the  forehead  and  over  the  top  of  the  head.  There  are  some 
pricking  sensations  in  his  face  but  no  severe  pains.  In  the  beginning 
the  gums  of  his  right  upper  jaw  were  sore  and  he  had  some  pain 
in  his  ear,  but  this  soon  disappeared.    Otherwise  he  has  always  been 


76  CLINICAL   SURGERY    BY    CASE    HISTORIES 

well.  Two  months  ago  he  had  alcohol  injections  for  the  pain.  He 
had  partial  relief  for  a  ver,y  few  weeks  onh*. 

Examination. — Both  eyelids  are  edematous  and  the  upper  one  and 
the  skin  over  the  supraorbital  ridge  are  red.  There  is  partial  loss 
of  sensation  over  the  eye  and  most  of  the  right  side  of  the  forehead. 
Sensation  in  the  face  is  normal.  The  pupil  of  the  right  eye  is  irregu- 
lar. Both  pupils  react  sluggishly  to  light  and  accommodation.  The 
eye  grounds  arc  normal.  The  reflexes  are  active.  Blood  pressure 
140-90.  Two  blood  Wassermanns  were  positive  and  one  negative.  The 
cell  count  of  spinal  fluid  slightly  increased. 

Diafjuosis. — The  sudden  onset  with  corj^za  causes  one  to  think  flrst 
of  a  frontal  sinus  infection.  The  associated  erysipelatous  infection, 
assuming  tliat  there  was  such,  may  have  been  a  continuation  of  this 
infection.  The  tissues  now  have  the  feel  of  a  posterysipelatous  le- 
sion. It  would  be  unusual  for  the  swelling  to  last  so  long  after  the 
attack.  It  is  possible  that  the  swelling  is  due  to  the  alcohol  injections 
made  two  months  ago.  If  so,  the  injection  must  have  been  unskillfully 
done,  an  assumption  not  warranted  because  it  was  made  by  a  person  of 
ample  exjierience.  If  due  to  the  original  lesion,  the  continued  thicken- 
ing may  account  for  the  pain  complained  of.  There  is  now  no  evidence 
of  frontal  sinus  infection,  rhinoscopically  or  on  x-ray  examination. 
The  irregular  pupil  and  sluggish  reaction,  together  with  the  dubious 
laboratory  findings  might  be  taken  to  indicate  the  presence  of  syphilis. 
Be  this  as  it  may,  that  would  not  account  for  the  swelling  or  for  the 
character  of  the  pain.  This  may  be  kept  in  mind  as  a  reserve  diag- 
nosis. 

Treatment. — He  was  placed  on  ascending  doses  of  potassium  iodide. 

After-course. — He  rapidly  improved  under  this  treatment  and  soon 
secured  complete  relief. 

Comment. — The  improvement  following  the  treatment  may  be  con- 
sidered as  evidence  of  syphilis,  but  the  same  drug  often  produces 
good  results  in  other  exudative  lesions.  At  present  the  diagnosis  is 
still  unsettled.  At  any  rate,  there  is  no  evidence  of  any  relation  to 
tic  and  operation  is  not  advisable. 

CASE  9. — A  farmer  aged  fifty-six  came  to  the  hospital  because 
of  pain  in  the  back  of  the  head. 

History. — Some  years  ago  he  had  a  severe  pain  in  the  back  of  his 
head.     After  a  few  Aveeks  it  gradually  improved.     He  has  had  sev- 


DISEASES    OF    THE    FACE    AND    ACCESSORY    SINUSES 


77 


era!  lesser  attacks  in  the  intervening  time.  SeA^eral  months  ago  the 
pain  retnrned  with  renewed  intensity.  He  has  not  been  free  from 
pain  day  or  night  during  that  interval  except  when  under  the  influence 
of   hypodermics.      He    covers    the    occipito-parietal   region   with   his 


Fig.  24. — Direction   in  which   the  needle  should  be  passed  to   reach   the   great   occipital   nerve. 

hand  when  asked  to  indicate  the  site  of  his  suffering.  His  general 
health  has  always  been  good  and  he  knows  of  no  cause  for  his  trouble. 
Examination. — The  point  of  greatest  sensitiveness  is  midway  be- 
tween the  external  occipital  protuberance  and  the  spine  of  the  first 
cranial  vertebra    (A^alleix's  point),   and   a   point   over   the   superior 


78  CLINICAL    SURGERY    BY    CASE    HISTORIES 

curved  line  a  fiiigerbreadth  lateral  to  the  external  oceipital  pro- 
tuberance. (Fig.  24.)  There  is  no  pain  or  limitation  in  the  movements 
of  the  head  or  other  evidence  of  disease  in  this  region.  Pain  is  caused 
by  active  movement. 

Diagnosis. — The  absence  of  any  etiologic  factor  which  might  cause 
a  neuritis  compels  the  diagnosis  of  a  neuralgia  of  the  great  occipi- 
tal nerve. 

Treatment. — A  one  per  cent  quinine  urea  hydrochloride  solution 
was  injected  at  a  point  a  fingerbreadth  lateral  to  the  spine  of  the 
first  cervical  vertebra  on  a  line  connecting  this  point  with  the  tip 
of  the  mastoid.  The  tip  of  the  needle  was  passed  through  the  trape- 
zius and  complexus.  The  nerve  lies  under  the  latter  muscle.  A 
few  c.c.  of  the  solution  were  injected  here.  The  needle  was  passed 
obliquely  upward,  after  withdrawing  from  the  muscles,  and  in  the 
direction  of  the  point  where  the  nerve  becomes  subcutaneous.  Some 
of  the  solution  was  injected  at  various  i)oints  along  the  course.  In 
all  an  ounce  of  the  solution  was  used. 

After-course. — Relief  came  in  a  few  hours  and,  while  there  was 
local  soreness  from  tlu^  irritation  of  the  quinine,  he  was  able  to 
sleep.  A  second  injection  was  made  a  week  later.  He  has  remained 
free  from  pain. 

Comment. — I  have  injected  many  of  these  cases  and  if  this  treat- 
ment fails,  the  patient  is  almost  sure  to  have  a  positive  Wassermann. 
These  neuralgias  are  associated  with  myalgias  just  as  lumbago  and 
sciatica  are  linked  together.  The  modern  viewpoint  seems  to  indicate 
a  frequent  association  with  some  articular  involvement  but  in  most 
cases  it  can  not  be  demonstrated.  In  actual  arthritic  involvement  in 
spondylitis  this  type  of  affection  does  not  occur. 

TUMORS  OF  THE  FACE 

In  no  other  region  of  the  body  does  a  mere  name  mean  so  little 
in  designating  the  character  of  the  tumor  as  in  the  face.  An  epithe- 
lioma may  mean  anything  from  a  semibenign,  basal-celled  epithelioma 
to  the  very  malignant  carcinomas  of  the  lip.  A  sarcoma  may  mean 
an  epulis  or  a  malignant  osteosarcoma.  Each  individual  tumor  has 
its  own  peculiarities.  No  matter  how  experienced  the  observer,  he 
will  still  have  rude  surprises  in  diagnosis  and  prognosis. 


DISEASES   OF    THE   FACE   AXD   ACCESSORY   SINUSES 


79 


CASE  1. — A  retired  farmer  of  sixty-five  came  to  the  hospital  be- 
cause of  an  enlargement  of  the  end  of  the  nose. 

History. — The  eucl  of  his  nose  has  been  enhirging  for  sixteen 
years.  It  has  never  eansed  any  pain  or  inconvenience  until  the  past 
year.  Now  when  he  drinks  coffee  the  end  of  the  mass  dips  into  the 
coffee  so  that  he  must  drink  it  cooler  than  he  likes  in  order  to  keep 
from  burning  the  end  of  his  nose.  He  wants  hotter  coffee,  hence  he 
seeks  relief.    He  has  never  liad  any  digestive  disturbance. 

Examination. — The  end  of  his  nose  presents  an  irregular  lobular 
mass  2  hj  214  inches  in  size  (Fig.  25).    It  is  somewhat  boggy  to  the 


Fig.  25. — Ehinophyma  showing  the  condition  before  and  two  weeks  after   operation.     The  tip 
of  the  nose  is  not  yet  complete!}'  healed  over. 

feel  and  may  be  twisted  in  any  way  without  eliciting  the  interest 
of  the  patient.     Examination  otherwise  is  negative. 

Diagnosis. — The  irregular  size  and  long  duration  of  the  trouble 
stamps  it  as  an  rhinophyma. 

Treatment. — The  excess  mass  was  shaved  off'  with  a  scalpel  until 
the  general  outlines  suited  the  esthetic  sense  of  the  operator.  Xo  at- 
temjDt  at  grafting  was  clone,  the  denuded  area  being  allowed  to  cover 
of  its  own  accord. 

PatJioIogy. — The  cut  surface  of  the  mass  removed  was  of  a  grayish 
white  and  dotted  over  with  small  whitish  points.     The  slide  showed 


80 


CLIXICAI.    SIRGKRY    BY    CASK    HISTORIES 


a  fibrocellular  backgrouiul  with  a  marked  dilatation  and  hypertrophy 
of  the  sebaceous  glands  (Fig.  26). 

Aftcr-conrse. — In  two  weeks  the  denuded  surface  had  become  com- 
pletely covered  by  a  new  epithelium  except  for  a  small  area  at  the 
point  (Fig.  25B)  where  the  cartilage  had  been  removed  in  order  to 
reduce  the  length  of  his  nose. 

Comment. — It  is  likely  that  nests  of  cells  from  the  sebaceous  glands 
take  part  in  the  epithelization  process,  else  it  would  not  be  covered 


Fig.    26. — Section   from    rhinophyma   showing   the   increase   in   the   sebaceons   glands   and    con- 
nective tissue. 

so  rapidly.     The  grafting  of  skin  on  the  denuded   area   sometimes 
recommended,  is  entirely  superfluous. 


CASE  2. — A  merchant  aged  forty-four  comes  because  of  a  tumor 
of  his  cheek. 

History. — For  several  years  the  patient  has  been  aware  that  there 
was  a  tumor  the  size  of  a  pea  in  his  left  cheek.  It  caused  him  no 
trouble  until  recently  when  it  began  to  enlarge  rapidly  and  become 
quite  painful. 


DISEASES    OF    THE    FACE    AND    ACCESSORY    SIXUSES  81 

Examination. — There  is  a  hemispherical  tumor  the  size  of  a  small 
hickory  nut  behind  and  an  inch  below  the  angle  of  the  month.  The 
skin  over  it  \ras  reddened  and  attached  to  the  tumor.  The  deeper 
portions  of  the  tumor  seemed  to  be  free  from  the  surrounding  tissue 
as  determined  by  a  finger  introduced  into  the  mouth.  The  tumor 
is  soft,  semifluctuating,  and  tender  (Fig.  27). 

Biagnosis. — The  history  of  long  duration,  its  sudden  enlargement, 
reddened  surface,  and  its  close  relation  with  the  skin  characterized 
it  as  a  wen  which  had  recentlv  become  infected.    Had  it  been  in  di- 


Fig.   27. — Wen   of  the  cheek.      The   thinned   skin   covering  the   tumor   is  well   seen. 

rect  line  of  the  mouth  fold,  a  dermoid  would  have  had  to  be  con- 
sidered. Dermoids  seldom  become  inflamed  and  are  not  attached  to 
the  skin.  Occasionally  small  round-celled  sarcomas  begin  in  the  cheek 
as  globular  masses.  These  usually  occur  in  young  persons,  have  but 
a  brief  history,  and  are  attached  to  the  deeper  tissues  of  the  cheek. 

Ti-eatment. — An  elliptical  incision  was  made  about  the  summit  so  as 
not  to  open  into  the  tumor.  In  this  way  the  tumor  was  removed  in- 
tact. 

After-course. — Healing  was  prompt  and  the  result  permanent. 

Comment. — Had  this  tumor  been  on  the  cheek  of  a  woman.  I  should 
have  incised  and  allowed  the  infected  contents  to  escape.  After  heal- 
ing had  been  completed  I  should  then  have  removed  the  tumor.     In 


82  CLIXICAL   SURGERY   BY    CASE    HISTORIES 

this  way  a  finer  sear  would  have  been  produeed.  In  operating  these 
tumors  the  facial  nerve  and  Stenson's  duct  must  be  remembered.  I 
have  seen  one  instance  in  which  a  wen  of  this  region  became  malig- 
nant. In  such  instances  one  may  be  obliged  to  keep  his  eye  on  the 
tumor  rather  tlian  on  the  anatomic  structures  above  noted. 

CASE  3. — A  student  aged  thirty  came  to  me  because  of  a  tumor 
on  his  face. 

Ilistorij. — Some  months  ago  he  noticed  a  tumor  developing  in  his 
cheek.  After  a  month  it  discharged  spontaneously  for  a  time  and 
then  healed,  leaving  a  dimpled  scar.  After  a  time  the  tumor  began 
to  re-form.  In  the  last  day  or  so  it  has  become  painful  again  and  has 
increased  much  in  size. 


Fig.    28. — Chronic    alveolar   abscess   simulating  a   wen. 

Examination. — Posterior  to  and  below  the  angle  of  the  mouth  is 
a  tumor  the  size  of  a  hazelnut.  It  is  firmly  fixed  to  the  skin,  less 
so  to  the  surrounding  tissues,  and  does  not  seem  to  be  fixed  to  the 
underlying  tissues.  The  teeth  seem  to  be  unatfected  and  there  seems 
to  be  no  connection  between  the  tumor  and  the  jaw  bone.     (Fig.  28.) 

Diagnosis. — The  form  of  the  tumor,  its  attachment  to  the  skin  and 
its  freedom  from  attachment  to  the  jaw  seem  to  stamp  it  as  a  wen 
which  has  become  infected  and  ruptured  spontaneously. 

Treatment. — The  tumor  was  excised.  It  was  noted  that  there  was 
no  encapsulation  and  the  tumor  was  directly  attached  to  the  sur- 
rounding tissue.  The  wall  of  the  abscess  extended  to  the  bone  and 
contained  thick  pus  without  epithelial  lining. 

Pathology. — "When  the  tumor  was  sectioned,  it  was  discovered  that 
the  sac  wall  was  composed  of  granulation  tissue  Avithout  epithelial 
lining. 


DISEASES    OF    THE   FACE   AND   ACCESSORY    SINUSES  83 

After-course. — True  to  the  predictions,  warranted  by  the  study  of 
the  section,  a  fistula  formed.  The  corresponding  area  of  the  jaw  was 
then  exposed  under  nerve  blocking  and  a  bit  of  necrotic  bone  found. 
This  was  gouged  out  and  the  root  of  the  tooth  pointing  in  a  root  ab- 
scess was  amputated.  The  sinus  from  the  region  of  the  bone  to  the 
cheek  was  removed.     Healing  now  is  permanent. 

Comment. — There  was  no  complaint  pointing  to  a  primary  tooth 
abscess.  The  whole  complaint  had  to  do  with  the  cheek,  and  I  ascribed 
it  to  an  infected  wen.  The  deep  dimple  remaining  could  not  have 
come  from  a  suppurating  wen  and  spelled  certainly  that  the  process 
came  from  a  deeper  point.  The  attachment  to  the  skin  extended 
over  a  wider  area  than  is  the  case  in  an  infected  wen  and  the  wall 
was  thicker. 

CASE  4. — A  matron  fifty-four  years  of  age  came  to  the  hospital 
because  of  an  ulcer  about  the  nose. 

History. — A  dozen  or  more  years  ago  she  first  noticed  an  ulcer 
at  the  junction  of  the  side  of  the  nose  and  lip.  She  was  treated  many 
years  with  various  salves  without  result.  She  consulted  a  dermatolo- 
gist who  diagnosed  lupus  and  treated  it  for  several  months  with  the 
x-ray.  The  ulcer  seemed  but  to  grow  the  faster  after  this  treatment. 
Save  for  the  slight  irritation  and  the  esthetic  aspect,  she  was  not 
annoyed. 

Examination. — The  patient  shows  an  ulcerous  lesion  which  has 
largely  destroyed  the  right  ala  (Fig.  29),  extends  a  centimeter  along 
the  floor  of  the  nose,  and  reaches  to  the  inner  surface  of  the  opposite 
ala.  The  edge  is  slightly  indurated  and  hard  to  the  touch.  No  tu- 
bercles can  be  found  with  the  slide  test. 

Diagnosis. — Save  for  the  slow  growth,  it  does  not  resemble  lupus. 
The  growth  is  too  slow  also  for  a  syphilitic  lesion.  The  undermined 
edge  with  a  dense  border  suggests  basal-celled  epithelioma. 

Treatment. — The  diseased  area  was  widelj"  excised  and  the  defect 
remedied  by  a  plastic  operation. 

Patliology. — The  tissue  was  typical  basal-celled  epithelioma. 

After-course. — There  was  a  recurrence  along  the  floor  of  the  nasal 
cavity.    Death  occurred  two  years  after  operation. 

Comment. — Dermatologists  rarely  use  the  x-ray  with  sufficient  vigor 
to  destroy  a  tumor  of  this  character  in  this  situation.    "When  a  basal- 


84 


CLIXICAL    SIKGKRY    BY    CASK    HISTORIES 


celled  epithelioma  once  invades  the  mucous  membrane  of  the  nose, 
the  chance  of  cure  b}^  any  means  is  not  very  good.  Very  wide  ex- 
cision must  be  practiced.  The  basal-celled  carcinomas  lose  their 
relatively  benign  character  when  they  invade  mucous  membrane. 
The  x-ray  seems  to  be  entirely  useless.  The  very  slow  growth  with 
tendencies  to  heal  in  some  places  causes  the  resemblance  to  lupus 
to  be  quite  close. 


Fig.   29. — Basal-celled   carcinoma   of  the   alx   of   the   nose. 

CASE  5. — A  farmer  aged  fifty-six  came  to  the  hospital  because 
of  multiple  ulcers  of  his  cheek. 

History. — For  seven  years  he  has  noticed  numerous  scaly  patches 
developing  on  his  face.  These  patches  at  first  scaled  only,  later  when 
the  scales  were  forcibly  detached  slight  bleeding  w^ould  occur.  The 
larger  of  them  on  the  right  temple  is  now  permanently  scabbed  over 
and  when  he  removes  these  considerable  oozing  of  blood  takes  place. 

Examination. — The  patient  is  a  thin,  large-boned  man  of  complex- 
ion vulgarly  known  as  "sorrel  top."  In  innumerable  places  over 
the  entire  face  and  sides  of  the  neck,  particularly  on  the  right  temple, 
are  patches  as  above  described.  The  larger  one  when  deprived  of 
its  crust  oozes  and  the  edges  are  seen  to  be  irregular  and  undermined. 
The  border  is  somewhat  elevated  above  tlie  surrounding  skin. 


DISEASES    OF    THE    FACE    AND    ACCESSORY    SINUSES 


85 


Diagnosis. — The  gradual  development  of  the  lesion  here  described 
indicates  a  change  from  seborrheic  patches  to  basal-celled  epithelioma. 
Occurring  in  such  numbers  in  blond  persons  these  tumors  are  some- 
times called  sun  cancers.  The  theory  is  that  the  skin  being  little  pro- 
tected by  pigment  is  susceptible  to  the  sun's  rays,  the  irritation  re- 
sulting in  these  proliferations. 

Treatmeni. — He  was  sent  to  a  roentgenologist. 

After-course. — Relief  seemed  to  be  complete  after  a  few  treatments. 
Late  results  are  not  known. 


Fig.    30. — Beginning   basal-celled    epitheliomas    of    the    temple. 


Comment. — Some  of  these  are  treated  with  radium  by  dermatolo- 
gists but  a  capable  roentgenologist  will  accomplish  the  work  much 
more  certainly  and  quickly.  These  multiple  lesions  usually  respond 
to  the  x-ray.  Sometimes  one  will  persist  in  spite  of  the  ray  or  recur 
quickly  after  being  healed.  This  is  particularl}^  apt  to  take  place  in 
those  situated  above  the  level  of  the  outer  canthus  of  the  eye  as  in 
the  larger  one  shown  in  Fig.  30,  or  in  those  on  the  neck  below  the 
angle  of  the  jaw.  Wlien  these  do  not  respond  readily  to  the  x-ray, 
excision  should  be  done,   and  if  situated  on   the  neck,   the  excision 


86 


CLINICAL   Sl'RGERY    BY    CASE    HISTORIES 


should  be  radit-al, — a  wide  cut  including  .superficial  fascia  and  pla- 
tysma. 

CASE  6. — A  farmer  aged  fifty-six  came  to  the  hospital  because 
of  several  small  tumors  of  his  cheek. 

Ilisforij. — For  many  years  he  luis  had  scaling  patches  over  various 
regions  of  his  face.  During  the  past  three  years  three  of  these  near 
the  angle  of  his  mouth  have  formed  ainioying  crusts.  AVhen  these 
were  removed,  oozing  of  blocd  took  place.  He  is  a  ranchman  and  has 
alwavs  lived  out  of  doors. 


Fig.  31. — r.asal-celled  epitheliomas  beginning  as  warty  growths. 

Exam i)iaf Ion. — The  ])atient  is  tall  and  slender  and  generally  deli- 
cateh'  built.  His  skin  is  soft,  his  hair  like  the  sands  of  the  plains.  On 
his  right  cheek  near  the  angle  of  the  mouth  are  three  elevations  about 
as  large  as  a  pea.  Their  surfaces  are  covered  with  scabs.  When 
these  are  removed  a  few  drops  of  blood  oozes  from  them.  AYhen  the 
surface  is  thus  exposed  a  wdiiti.sh  pink  mottling  can  be  detected. 
The  tumors  do  not  tend  to  become  ulcerated,  but  in  general  the  growth 
is  expansile.  Numerous  seborrheic  patches  were  present  over  various 
regions  of  the  face.    There  are  no  glands.     (Fig.  31.) 


DISEASES    OF    THE    FACE    AND    ACCESSORY    SINUSES  87 

Diagnosis. — From  their  form  one  would  think  first  of  adenomas 
but  the  history  of  their  beginning  as  scaly  patches  negates  this,  par- 
ticularly as  the  patient  still  has  scaly  patches  which  he  exhibits  as 
replicas  of  the  early  history  of  the  now  more  important  lesions.  The 
conclusion  must  be,  therefore,  that  they  are  basal-celled  epitheliomas. 

Treatment. — The  tumors  were  excised  that  tissue  might  be  had  for 
examination  and  the  resulting  wound  cauterized  with  the  electric 
cautery.     The  x-ray  was  advised  for  the  seborrheic  patches. 

Pathology. — The  tumors  show  the  typical  picture  of  basal-celled 
epithelioma. 

After-course. — The  lesions  remained  healed. 

Comment. — Basal-celled  epitheliomas  when  flat  are  best  treated 
by  the  x-ray.  True  the  elevated  variety  may  be  destroyed  by  the 
x-ray  but  not  nearly  so  quickly  as  the  flat  kind.  Where  scarring  is 
of  less  importance  than  time  the  cautery  is  preferable.  Excision 
need  not  be  practiced  before  the  cautery  is  applied  unless  the  surgeon 
has  a  curiosity  as  to  the  histology  of  the  tumors,  which  must  be 
satisfied. 

CASE  7. — A  man  aged  sixty  was  brought  to  me  for  diagnosis  of 
a  tumor  in  front  of  his  ear. 


Fig.  32. — Warty  epithelioma  in  front  of  the  auditory  meatus. 

History. — This  patient  has  had  a  wart  in  front  of  his  ear  for  sev- 
eral years.  For  a  year  or  more  it  has  borne  a  scab  and  recently 
has  been  uncomfortable. 

Examination. — Just  in  front  of  his  ear  is  a  tumor  1  cm.  in  diame- 
ter.    It  has  a  wall  continuous  with  the  surrounding  skin.     This  wall 


88  CLINICAL    SIKGERY    BY    CASE    HISTORIES 

is  two  or  three  mm.  high  and  terminates  in  a  crusty  surface.  "When 
this  crusty  surface  is  removed,  an  oozy,  bleeding,  granulating  surface 
is  uncovered.  It  seems  to  involve  the  full  thickness  of  the  skin.  (Fig, 
32.)     No  glands  are  palpable. 

Diagnosis. — The  bleeding,  granulating  surface  stamps  it  as  malig- 
nant. The  history  of  an  antecedent  wart  and  the  location  about  the 
ear  stamps  it  as  of  the  graver  sort  of  epithelioma. 

Treatment. — Destruction  by  cautery  was  advised.  It  was  excised 
elsewhere. 

After-course. — Recurrence  began  in  a  year  and  the  patient  died 
two  3'ears  later. 

Comment. — Epithelial  tumors  in  front  of  and  below  the  ear  are 
particularly  likely  to  be  mischievous,  and  ext3nsive  destruction  by 
the  cautery  gives  better  results  than  even  wide  excision. 

CASE  8. — A  man  a^ed  sixty  was  broujht  for  my  delectation  by 
a  colleague. 

History. — He  has  had  a  small  tumor  below  his  eye  for  many  years. 
It  has  gradually  enlarged  until  it  has  attained  its  present  size.  It 
causes  no  inconvenience. 

Examination. — A  tumor  1  cm.  in  diameter  and  a  half  as  h'gh  is 
situated  lateral  to  the  ala  of  the  nose.  Its  surface  is  smooth,  is  en- 
crusted at  only  one  fine  point.  Small  lobulations  can  be  made  out. 
(Fig.  33.) 

Diagnosis. — The  presence  of  the  small  lobulations  and  the  absence 
of  ulcerations  and  encrustations  exclude  malignanc}'.  Its  close  asso- 
ciation with  the  skin  stamps  it  as  epithelial.  It  may  be  designated, 
therefore  as  a  benign  cystic  epithelioma. 

Treatment. — The  tumor  was  excised. 

Pathology. — The  tumor  is  made  up  of  long  masses  of  epithelial 
cells  containing  numerous  cysts  within  them.  The  cells  show  no  ten- 
dency to  degeneration  forms.      (Fig.  34.) 

After-course. — Nothing  is  known  but  it  may  be  confidently  stated 
that  cure  resulted. 

Comment. — Those  tumors  belonging  to  this  category  which  I  have 
been  privileged  to  study  seemed  to  be  derived  from  the  sebaceous 
glands,  and  in  my  opinion  had  best  be  designated  adenomas  of  the 
sebaceous  glands. 


DISEASES   OF    THE   FACE   AND    ACCESSORY    SINUSES 


89 


Fig.   33. — Benign  cystic  epithelioma  of  the   cheek. 


i# 


Fig.    34. — Cy.stic   epithelioma   showing   the   cavities   and    dense   cell   masses. 

CASE  10. — A  farmer  aged  sixty-two  came  to  the  hospital  because 
of  an  ulcer  on  his  face. 

History. — Seventeen  years  ago  he  began  to  have  canker  sores  on  his 
left  cheek.     A  year  ago  a  larger  nicer  than  nsnal  appeared  and  he 


90 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


had  his  teeth  extracted.  It  has  not  healed  since.  For  a  nnniber  of 
months  a  sore  has  been  developing  on  his  cheek.  His  health  remained 
unimpaired  nntil  six  weeks  ago.     Since  then  he  has  taken  only  li(|uid 


Fig.   35-.4. — Carcinoma  of  the  cheek. 


Fig.    35-B. — Tumor    after    excision    showing    the    oral    part    of    the    growth. 

nourishment  and  has  hj.st  12  pounds.     His  general  health  has  always 
been  good. 

Examination.— ^Udway  between  the  tip  of  the  cliin  and  the  angle  of 
the  jaw  is  a  tumor  raised  half  an  inch  above  the  surrounding  skin.  It 
is  an  inch  or  more  in  diameter  and  the  surface  is  red,  granular,  and 


DISEASES    OF    THE    FACE    AND    ACCESSORY    SINUSES 


91 


bleediiif];:  (Fig.  35-A).  There  are  no  glands  palpable.  The  inside  of 
the  cheek  is  occupied  by  a  fungating  mass  two  inches  across.  There 
is  an  extensive  pyorrhea.     The  urine  is  negative,  Bp.  165-100. 

Diagnosis. — The  history  of  an  ulcer  which  started  from  the  irritation 
of  a  broken  tooth  is  at  once  suggestive  of  carcinoma.  The  fragile 
nature  of  the  fungating  mass  leaves  no  doubt  of  it.  The  question 
is  to  determine  its  operability.  Being  fungating  the  likelihood  of 
metastasis  is  much  reduced,  but  the  chance  of  local  recurrence  is 
much  enhanced.    Wide  local  excision  is  the  requirement. 


Fig.  36. — Four  weeks  after  excision  of  carcinoma  of  the  cheek.     The  upper  part  is  completely 
healed   while   below    there    is    extensive    recurrence. 


Treatment. — The  growth  was  widely  excised  under  local  anesthe- 
sia. A  margin  of  healthy  mucosa  was  removed  with  the  tumor  (Fig. 
35-5).  The  opening  was  left,  the  idea  being  to  allow  the  cut  sur- 
face to  heal  over  in  order  to  see  whether  there  was  any  disposition  to 
recurrence. 

Pathology. — The  slide  showed  a  typical  carcinoma. 

After-course. — The  amount  of  tissue  removed  proved  to  be  whoU}' 
inadequate.  A  rapid  recurrence  took  place  all  about  the  lower  border 
(Fig.  36).     An  area  along  the  upper  border  healed  over  completely, 


92 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


showing  that  here  the  disease  had  been  controlled.  The  recurrent 
portion  was  removed  with  a  cautery  under  nerve  blocking.  After 
the  entire  circumference  was  controlled,  the  deficit  was  covered  by 


J'iy.   37.  —  Six   weeks  aftt-r  transplanting  a  skin  flap   from   tlie  neck  to  the  cheek. 

a  long  flap  from  the  neck.  The  skin  side  was  turned  into  the  mouth. 
After  this  had  healed,  the  pedicle  was  cut  and  folded  over  the  skin 
filling  the  deficit,  producing  in  this  way  a  covering  for  the  defect 
lined  Avitli  skin  witliin   and  without.     In  a  few  months  recurrences 


DISEASES   OF    THE   FACE   AND   ACCESSORY    SINUSES  93 

appeared  in  the  deep  cervical  lymph  glands  and  it  was  obvious  the 
attempt  at  cure  had  failed. 

Comment. — In  fungating  tumors  I  have  found  it  a  good  working 
plan  to  excise  the  tumor,  allowing  the  borders  to  heal  before  attempt- 
ing to  close  the  defect.  This  gives  a  good  opportunity  to  watch  for  re- 
currences. In  the  case  of  the  cheek,  this  is  particularly  desirable,  for 
if  a  graft  is  transplanted  at  once  and  a  recurrence  does  take  place, 
it  is  exceedingly  difficult  to  get  at  the  recurrent  area  because  of 
the  limitation  of  movements  of  the  jaw  that  follows  such  an  operation. 
If  in  securing  a  flap  for  filling  in  the  cheek  one  will  go  down  the 
back  of  the  neck  and  shoulder,  one  can  fill  the  defect  without  scarring 
the  neck  (Fig.  37).  If  one  uses  a  short  pedicled  flap,  the  neck  will 
be  badly  scarred. 

CASE  11. — A  farmer  aged  fifty-two  came  to  the  hospital  because 
of  a  tumor  in  his  cheek. 

History. — For  four  years  he  has  noticed  a  tumor  inside  of  his 
right  cheek.     It  grew  gradualh'  and  two  years  ago  it  was  burned 


Fig.    38-A. — Cauliflower   growth    of   the   cheek   after   excision. 


94 


CLINICAL    ST'RGERY    BY    CASE    HISTORIES 


out.  It  did  not  heal,  liowever,  and  the  growth  seemed  only  to  be  stimu- 
lated. It  now  interferes  with  the  taking  of  food  and  he  has  lost  some 
thirty  pounds  in  weight. 

Examinatiou. — A  mass  two  and  a  half  inches  in  diameter  and  more 
than  an  inch  thick  occupies  the  inner  surface  of  his  right  cheek. 
It  is  fungoid,  irregular  in  outline,  and  the  surface  is  fragile  and 
bleeds  on  manipulation.     There  are  no  palpable  glands  in  the  neck. 


Fig.   38-B. — Complete   cicatrization    of   the   area    excised. 


Biagnosis. — The  fungiform  outline  and  the  fragile  surface  indi- 
cates that  it  is  a  carcinoma.  The  fact  that  it  is  fungiform  gives 
the  hope  that  it  is  of  relative  benignancy.  This  hope  is  strengthened 
by  the  absence  of  lymph-gland  involvement.  In  view  of  these  facts 
operative  removal  seems  warranted. 

Treatment. — The  growth,  together  with  the  entire  thickness  of  the 
cheek,  was  removed  by  the  cautery  under  local  anesthesia.    The  large 


DISEASES    OF    THE   FACE   AND    ACCESSORY    SINUSES 


95 


wound  was  left  open  to  granulate  at  will.  After  the  border  had 
healed  a  flap  was  advanced  from  the  neck  and  the  back  of  the  shoul- 
der. The  skin  surface  was  turned  toward  the  interior  of  the  mouth. 
In  two  weeks  the  pedicle  was  cut  and  a  fold  was  placed  over  the 
original   graft   covering   the   wound.      In   this   way   the   defect   was 


Fig.  3S-C. — The  edges  of  the  stoma  shown  in  the  preceding  figure  were   coapted  and   retained 
by   means   of   traction   sutures. 

filled  in  by  a  graft  covered  by  skin  on  the  inside  and  on  the  outside. 

Pathology. — The  tumor  on  section  shows  the  cauliflower  arrange- 
ment (Fig.  38-A).  The  cell  columns  are  arranged  in  a  radiating  man- 
ner from  the  base.    The  slide  shows  a  typical  epithelioma. 

After-course. — The  wound  healed  completely,  but  in  nine  months 
there  were  signs  of  recurrence  in  the  region  in  front  of  the  pillars. 


96  CLINICAL    SURGERY    BY    CASE   HISTORIES 

The  growth  was  again  destroyed  and  allowed  to  heal  as  before.  This 
time  the  wound  was  allowed  to  thoroughh'  cicatrize  (Fig.  38-B)  be- 
fore attempts  at  repair  were  made.  The  edges  of  the  opening  were 
then  loosened,  separating  the  mucous  and  cutaneous  layers  and  then 
bringing  the  freshened  edges  in  apposition.  The  skin  edges  were  held 
together  by  tension  sutures  protected  by  pearl  buttons  (Fig.  38-C). 
The  opening  closed  without  further  trouble  and  has  remained  so. 

Comment. — The  treatment  here  outlined  was  whollj'  successful. 
Had  the  first  opening  been  allowed  to  remain  open  a  longer  time  be- 
fore the  grafting  was  undertaken  the  second  operation  would  not 
have  been  necessary.  The  removal  of  the  tumor  leaving  the  wound 
wide  open  until  cicatrization  has  been  complete  gives  a  much  better 
prognosis  in  many  carcinomas  of  the  face  than  the  old  method  of 
innnediate  plastic. 

DISEASES  OF  THE  ACCESSORY  SINUSES 

Diseases  of  the  sinuses  belong  partly  to  the  rhinologist  and  partly 
to  the  surgeon.  Those  curable  by  drainage  are  usually  claimed  by 
the  former,  while  those  requiring  major  operative  procedures  are 
usually  consigned  to  the  latter.  Even  those  ordinarily  curable  by 
drainage  when  long  neglected  may  require  extensive  operations 
for  their  cure  because  of  extensive  secondary  changes  that  have 
taken  place  in  their  walls.  The  chief  problem  which  the  surgeon 
mu.st  consider  is  whether  the  condition  is  due  to  neglected  drain- 
age on  the  part  of  the  rhinologist  or  whether  there  is  primarily  some 
disease  usualh'  neoplastic  which  lies  before  him.  The  disease  causing 
expansion  of  the  frontal  sinuses  is  usually  due  to  infection,  while 
neoplasms  are  the  most  common  cause  of  distention  of  the  antrum. 

CASE  1. — A  school  teacher  aged  thirty -two  came  because  of  a 
tumor  cf  the  orbit  which  was  displacing  her  eye. 

History. — Since  the  patient  Avas  fifteen  j-ears  of  age  she  has  noticed 
a  growth  involving  the  region  of  the  left  eye  and  temple.  She  first 
noticed  a  bulging  of  the  temple.  It  caused  no  trouble  save  for  its 
presence.  It  has  grown  slowly  since.  It  now  displaces  the  eye 
downward,  but  the  sight  is  unaffected  and  there  is  no  double  vision. 
She  has  never  had  anv  nose  trouble  or  headaches.     She  has  had  a 


DISEASES   OF    THE   FACE   AND   ACCESSORY   SINUSES  97 

moderate  goiter  for  seven  years  and  had  had  some  heart  trouble 
with  palpitation.    She  has  pain  in  the  back  and  dysmenorrhea. 

Examinaiion. — There  is  a  pronounced  bulging  in  the  temple  and 
in  the  orbit,  pushing  the  eyeball  a  centimeter  below  the  line  of  its 
fellow  (Fig.  39).  It  is  painless.  Pressure  over  the  temple  causes 
the  bone  to  crackle,  evidence  that  it  has  become  much  thinned.  The 
x-ray  shows  the  frontal  sinus  to  be  much  dilated. 

Diagnosis. — The  very  slow  growth  removes  this  tumor  from  the  ma- 
lignant group.  The  thinness  of  the  bone,  shown  both  by  the  x-ray 
and  by  the  crackling,  is  evidence  of  an  expanding  process  beneath 


Fig.   39. — Cholesteatoma.     The  picture  shows  the  displacement  of  the  eyeball  and  the  bulging 

in  the  temple. 

the  bone.  Because  of  the  bulging  of  the  roof  of  the  orbit  it  is  proba- 
ble that  the  bulging  in  the  temple  likewise  is  due  to  expansion  of  the 
frontal  sinus.  The  common  condition  which  would  produce  such  a 
state  is  a  mucocele. 

Treatment. — ^When  the  thin  crackling  bone  was  removed,  a  mass 
was  found,  silver  in  color  and  as  friable  as  cottage  cheese.  After 
the  mass  was  scraped  out,  a  cavity  as  large  as  a  turkey  egg  remained. 
The  cavity  at  the  median  extremity  ended  in  a  narrow  channel  but 
an  opening  into  the  nose  could  not  be  found.  The  mass  was  as 
readily  removed  from  the  anterior  wall  as  periosteum  from  the  nor- 
mal bone.     The  posterior  wall  for  an  area  as  large  as  a  half  dollar 


98  CLINICAL    SURGERY    BY    CASE    HISTORIES 

was  bare  of  bone  and  the  mass  had  to  be  removed  from  the  dura.  The 
removal  of  tiie  mass  left  the  dura  smooth  and  uninjured,  save  at  one 
point  where  some  bleeding  occurred. 

PatJto'ogy. — No  cellular  elements  could  be  found  in  the  material 
removed  save  about  the  layer  lying  on  the  l)one.  The  material  re- 
moved has  the  appearance  of  that  seen  in  cholesteatoma.  The  pearly 
white  material  was  laminated  and  could  readily  be  separated  like 
the  layers  of  a  dried  onion.  The  cell-layer  demonstrable  was  no- 
where continuous. 

After-course. — Following  the  operation  much  serous  fluid  escaped 
carrying  with  it  flakes  of  the  mass  which  had  escaped  the  curette.  At 
the  end  of  several  months  the  entire  cavity  obtained  a  smooth  lining 
and  an  opening  the  size  of  a  lead  pencil  in  the  temple  remained. 
She  so  arranges  her  hair  that  it  covers  this  opening.  The  eye  grad- 
ually receded  to  its  normal  position. 

Comment. — The  material  had  the  appearance  of  the  contents  of 
a  wen.  It  seems  hardly  j^ossible  that  a  purulent  accumulation  could 
have  produced  such  a  mass  of  material.  It  seems  warranted  to  make  a 
diagnosis  of  cholesteatoma.  Whether  or  not  there  may  have  been  some 
primary  connection  between  the  mass  where  the  dura  lay  free  of  bone, 
or  whether  the  bone  became  eroded  in  the  process  of  the  development 
of  the  mass  can  not  be  determined.  Considering  the  general  genesis 
of  cholesteatomas  the  first  proposition  seems  quite  acceptable.  Con- 
sidering the  generally  accepted  opinion  that  cholesteatomas  are  epi- 
dermoidal  in  origin,  it  is  difftcult  to  understand  the  genesis  of  this 
tumor.  However,  a  number  of  cases  have  been  reported  much  like 
this,  in  all  of  which  the  dura  lay  exposed  at  one  point.  A  possible 
relation  to  the  odontomas,  supposedly  congenital  in  this  region,  may 
be  considered.  At  any  rate  the  location  in  the  frontal  sinus  is  not 
so  hard  to  conceive  as  are  those  situated  in  the  lowcn^  jaw,  of  which 
several  have  been  reported. 

CASE  2. — A  telegraph  operator  came  to  the  hospital  because  of  a 
gradual  enlargement  of  the  skull  over  his  eye  and  displacement  of 
his  eye. 

History. — This  patient  has  noticed  a  disproportionate  size  of  the 
bones  over  his  eyes  for  some  fifteen  years.  For  the  past  five  years  he 
has  noticed  a  downward  displacement  of  the  eye  on  the  prominent 
side  and  now  he  is  sometimes  annoyed  by  double  vision.  He  has  had 
no  pain.     He  has  had  no  marked  trouble  with  his  nose  that  he  can 


DISEASES    OF    THE    FACE    AXD    ACCESSORY    SINUSES 


99 


Fig.    40. — Osteoma   of  the   frontal   sinus. 


Fig.  41. — The  large  clear  area  shows  the  size  of  the  cavity  occupied  bj'  the  newly  formed  bone. 


now  recall.    He  recent!}-  consulted  a  snrgeon  who  diagnosticated  sar- 
coma and  refused  operation. 

Examination. — There  is  a  general  prominence  of  the  left  supra- 
or-hital   ridge    amonnting   to    an    elevation    of    a    centimeter    and   a 


100  CLTNICAli   SURGERY    BY    CASE    HISTORIES 

half  aljove  the  ridg'e,  and  the  roof  of  the  orbit  is  depressed  a  like 
distance  (Fig.  40).  It  is  very  dense  and  altogether  painless  to  pres- 
sure. The  corresponding  eye  is  displaced  a  like  distance  downward. 
The  x-ray  (Fig.  41)  shows  a  clear  space  the  size  of  an  egg.  The 
border  is  thin  and  nowhere  shows  a  deeper  shadow  than  the  normal 
bone  septte.  The  eye  is  displaced  downward  and  outward  a  third  of 
an  inch. 

Diagnosis. — The  general  eidargement  of  the  cavity  indicates  a  grad- 
ual expansion  from  within.  Because  of  the  slow  development  the 
process  is  evidently  benign.  The  contents  must  consist  of  a  soft 
material,  or  of  bone  less  dense  than  the  normal  bone  sept*  of  the  skull. 
This  rules  out  the  eburnated  osteomas  of  the  sinus.  The  walls  of  the 
sinus  instead  of  being  thinned,  as  is  the  case  in  mucocele,  are  actually 
thickened.  This  suggests  an  associated  osteogenetic  process.  The 
diagnosis  seems  to  be  a  mucocele  with  osteogenetic  reaction.  If  the 
contents  is  bone  it  must  be  very  rare  bone. 

Treatment. — The  enlargement  was  opened  into  from  the  temple  re- 
gion. The  contents  were  found  to  be  loose,  cancellated  bone  which 
could  be  readily  removed  with  the  gouge  and  bone  curette.  A  shell 
of  compact  bone  surrounded  it  everywhere.  A  dilated  cavity  was 
found  in  the  region  of  the  ethmoid  cells.  Here  the  bony  capsule  was 
very  thin.  When  the  soft  bone  was  removed  there  remained  a  cavity 
the  size  of  an  egg,  the  walls  of  which  were  thick  and  eburnated.  The 
prominent  portions  of  the  shell  were  removed  and  the  wound  closed 
without  drainage. 

PatJioIogif. — The  bone  removed  had  the  structure  of  cancellated  bone 
about  the  structure  of  that  in  the  head  of  the  tibia. 

After-course. — It  was  hoped  the  pressure  of  the  orbital  contents 
would  so  displace  the  roof  of  the  orbit  that  the  eye  would  return  to 
its  normal  position.  This  did  not  take  place,  however.  A  second  op- 
eration was  done  which  removed  a  part  of  the  plate,  but  fear  of  in- 
juring the  optic  nerve  kept  me  from  going  back  far  enough,  and  but 
little  improvement  resulted.  The  bone  removed  from  here  was  trans- 
planted into  the  cavity  left  after  the  removal  of  the  tumor  tissue. 
This  in  large  measure  remedied  the  deformity  resulting  from  the 
first  operation. 

Comment. — The  genesis  of  this  tumor  evidently  is  from  the  sur- 
rounding walls  of  the  sinus.  The  stimulus  to  this  growth  may  have 
lain  in  a  low  degree  of  infection  though  there  is  nothing  in  the  his- 


DISEASES    OF    THE   FACE    AND   ACCESSORY    SINUSES 


101 


tory  to  give  any  clew.  The  literature  on  this  type  of  tumor  is  too 
meager  to  offer  any  aid.  The  history  and  physical  findings  of  this 
case  resemble  very  closely  those  of  the  preceding  case.  The  chief 
difference  lay  in  the  character  of  the  contents. 

CASE  3. — A  school  girl  aged  nine  was  brought  to  me  because  of 
a  swelling'  above  the  eye. 

History. — For  several  years  it  has  been  noted  that  there  was  an  en- 


Fig.   A2-A. — Osteoma  of  the   frontal   sinus   showing  bulging  of  the   temporal   surface.     B. — De- 
pression of  the  roof  of  the  orbit. 


largement  above  the  right  eye.  There  has  been  no  inconvenience 
caused  by  it. 

Examination. — At  the  lateral  part  of  the  supraorbital  ridge  there 
is  a  protrusion  amounting  to  an  elevation  of  a  centimeter  (Fig.  42). 
It  is  firm  to  the  touch  and  quite  painless.  The  x-ray  shows  a  dark 
shadow  without  any  difference  in  the  center  of  the  tumor.  Neither 
the  cerebral  cavity  nor  the  orbit  is  invaded. 

Diagnosis. — The  tumor  seems  to  involve  the  frontal  sinus.  Os- 
teomas are  the  most  common  tumor  of  this  region  and  while  they  are 


102  CLINICAL    SUKGEKY    BY    CASK    HISTORIES 

said  to  begin  in  childliood  it  is  unusual  for  them  to  come  to  observa- 
tion at  so  earh'  a  stage.  Considering  the  undeveloped  state  o£  the 
sinuses  at  this  age  this  seems  the  only  diagnosis  possible. 

Treatment. — An  incision  was  made  along  the  supraorbital  crest 
and  the  tumor  exposed  from  the  orbital  side.  When  the  plate  was 
chiseled  through  a  small  tumor  the  size  of  a  large  bean  was  extracted. 

Pathology. — The  mass  I'emoved  was  dense  bone  l)ut  with  some  can- 
cellations. 

After-course. — The  wound  healed  (piickly  and  without  apparent 
scar. 

Co))iiiunt. — This  ease  seems  to  substantiate  the  belief  that  frontal 
sinus  osteomas  originate  from  a  congenital  anlage.  This  tumor,  con- 
trary to  the  rule,  developed  from  the  lateral  end  of  the  sinus  while 
the  usual  site  is  at  the  nasal  extremity  of  it. 

CASE  4. — A  housewife  aged  thirty-six  came  to  the  hospital  be- 
cause of  a  tumor  which  was  displacing-  the  eye. 

History. — The  patient  is  tlie  mother  of  ten  children.  Her  father 
died  of  tuberculosis.  When  four  years  of  age  the  patient  fell,  strik- 
ing her  face  on  a  flat-iron.  Shortly  after  that  a  swelling  was  noticed 
above  and  to  the  inner  side  of  the  left  eye.  Following  this  whenever 
her  face  was  exposed  to  a  cold  wind  she  had  a  severe  pain  over  her 
left  eye.  Tliere  has  been  no  abnormal  discharge  from  the  nose. 
The  tumor  gradually  increased  and  the  pain  became  more  severe. 
She  has  been  examined  by  a  number  of  doctors  all  of  whom  pro- 
nounced the  tumor  of  bony  cluiracter.  Sometimes  there  is  no  pain. 
At  these  times  she  thinks  the  tumor  is  softer. 

Examination. — The  patient  presents  the  appearance  of  a  hard  work- 
ing woman  who  has  borne  10  children.  The  pupil  of  the  left  eye 
is  displaced  downward  and  lateralward  about  2  cm.  (Fig.  43).  The 
sight  in  this  eye  is  i^ractically  nil.  The  supraorbital  ridge  is  not 
displaced,  but  below  it,  particularly  in  tlie  medial  portion  of  the  orbit, 
is  a  rounded  tumor.  This  is  slightly  sensitive  to  pressure  and  the 
covering  bone  can  be  made  to  crackle. 

Diagnosis. — The  tumor  gives  the  impression  of  being  formed  by  the 
depression  of  the  orbital  wall  of  the  frontal  sinus.  The  cracking  of 
the  bone  indicates  that  the  depression  is  caused  by  a  fluid  or  semi- 
solid material.  Because  of  the  very  slow  growth  the  material  is 
probably   tlie   ]>roduet   of   tlie   lining  membrane   and   not   neoplastic. 


DISEASES    OP    THE    FACE    AND    ACCESSORY    SINUSES 


103 


A  bony  growth  would  have  remained  hard.  Besides  the  x-ray  shows 
a  cavity. 

Treatment. — An  incision  was  made  beneath  the  supraorbital  border 
on  the  inner  portion.  The  covering  of  bone  could  readily  be  elevated 
and  removed.  The  contents  of  the  cavity  so  exposed  was  a  thick 
creamy  substance  containing  some  whiter  and  more  dense  flakes.  The 
cavity  was  smooth  walled  and  noAvhere  showed  a  defect.  It  was  gently 
curetted  and  loosely  packed  with  gauze  and  the  wound  reduced  to 
a  small  opening. 

Pathology. — The  material  removed  was  structureless  and  bacteria- 
free. 

After-course. — There  was  considerable  discharge  for  a  number  of 


Fig.   43. — Mucocele   of  the   frontal   sinus. 

weeks,  probably  because  of  infection  from  without.  The  temperature 
varied  from  99.5°  to  101.5°  for  ten  days.  Healing  finally  followed. 
The  eye,  now  a  year  and  a  half  after  operation,  has  receded  half  the 
distance,  but  the  sight  has  not  improved. 

Comment. — Following  a  trauma  it  is  possible  the  opening  from  the 
sinus  was  closed  by  the  injury.  An  inflammation  may  have  been  set 
up  without  a  closing  of  the  opening,  but  there  is  no  history  of  abnor- 
mal discharges.  Such  a  negative  history  is  of  little  value  for  the  nor- 
mal discharges  in  a  child  are  often  sufficient  to  cover  up  the  added 
discharge  from  the  sinus.  Bearing  the  disfigurement  for  thirty  years, 
it  is  possible  that  the  environment  was  not  unduly  sensitive  to  es- 
thetic observations.     No  doubt  the  removal  of  more  of  the  orbital 


104 


CLIXICAL    SURGERY   BY    CASE    HISTORIES 


plate  would  induce  the  eye  to  further  recede  into  the  socket.  This 
would  imjirove  the  appearance,  without,  however,  restoring  the  atro- 
phied optic  nerve.  Looks,  however,  is  not  the  factor  of  prime  im- 
portance. She  looks  good,  no  doubt,  to  her  numerous  family,  and 
tinkering  in  this  region  is  not  without  a  small  element  of  danger. 

CASE  5. — A  farmer  aged  fifty-one  came  to  the  hospital  because  of 
a  tumor  of  his  right  cheek. 

History. — About  thirty  years  ago  he  had  one  of  the  right  upper  bi- 
cuspid teeth  pulled  on  account  of  severe  aching  and  it  was  found  to 


Fig.   44. — Prominence   of   the   superior  maxilla  due   to   a  carcinoma   of   the   antrum. 

be  '"ulcerated"  at  the  roots  when  pulled.  Two  to  three  weeks  later 
the  gums  swelled  at  the  site  of  the  pulled  tooth.  It  was  opened  and 
pus  drained.  Had  some  pain  at  the  time  but  he  is  not  definite  as  to 
whether  the  pain  was  facial  or  at  the  site  of  the  swollen  gum.  For 
thirty  years  there  has  been  drainage  into  the  mouth  from  the  place 
where  the  gum  was  lanced.  This  drainage  was  intermittent,  stop- 
ping for  two  to  three  days  at  a  time  but  no  longer.  The  drainage 
was  yellow,  smelled  and  tasted  very  bad.  There  was  very  little  pain 
at  any  time  during  the  thirty  years.  Six  months  ago  the  drainage 
stopped.     From  that  time  on  the  side  of  the  face  began  to  swell, 


DISEASES    OF    THE   FACE    AND   ACCESSORY    SINUSES 


105 


something  it  had  never  done  before.  The  swelling  has  been  slow  and 
its  progress  uniform.  The  swelling  has  always  been  somewhat  pain- 
ful, but  it  has  been  worse  during  the  last  three  months.  When  the 
enlargement  is  pressed  upon,  there  is  a  little  discharge  through  a 
sinus  into  the  mouth.  He  has  lost  no  weight.  The  patient  has  very 
little  headache.  His  general  health  is  good,  appetite  good,  bowels 
regular. 

Examination. — There  is  a  bulging  of  the  superior  maxillary  (Fig. 
44) .  The  skin  is  red  and  inflamed  in  appearance  over  the  tumor.  The 
tumor  is  not  very  tender  to  ordinary  pressure,  but  somewhat  tender  to 


Fig.    45. — Carcinoma   of   tlie   antrum    showing   large    cells,    some    of    whicli    have    retained    the 

intercellular   bridges. 

rather  hard  pressure.  The  teeth  are  badly  affected  with  pyorrhea. 
There  is  a  sinus  in  the  alveolar  process  on  the  right  side  of  the 
cheek  about  opposite  the  second  bicuspid.  On  pressure  over  the 
tumor  stroking  downward  a  serosanguinous  fluid  with  a  very  foul 
odor  escapes. 

Diagnosis. — The  history  of  long  standing  discharge  with  the  ap- 
pearance of  a  tumor,  evidently  due  to  an  expansion  of  the  antrum 
of  Highmore  would  seem  to  suggest  that  what  had  been  escaping 
was  retained  within.  The  expansion  of  the  bone  in  an  adult  would 
hardly  occur  in  so  short  a  time  from  the  products  of  a  pyogenetic 
membrane.     The  long-continued  suppuration  may  have  resulted  in 


106  CLINICAL    8L'RGERY    BY    CASE    HISTORIES 

a  neoplastic  process — a  sarcoma  or  what  is  more  common  in  tliis  sit- 
uation, a  myxosarcoma.     In  either  event  the  condition  is  operable. 

Treatment. — An  incision  was  made  in  the  skin  over  the  tumor.  The 
malar  and  upper  maxilla  were  partly  destroyed.  The  tumor  was  of 
a  soft,  friable  tissue.  It  was  removed  with  a  curette.  The  hard  pal- 
ate was  eroded,  the  mouth  and  the  right  nasal  fossa  Ijeing  opened 
in  curetting  out  the  tumor  tissue.  The  cavity  was  tightly  ])acked 
through  the  opening  into  the  mouth  and  the  skin  incision  closed. 
In  about  eight  days  the  pack  was  removed  from  the  antrum,  bring- 
ing with  it  a  considerable  amount  of  sloughing  tissue. 

PatJioIogy. — The  tissue  removed  consisted  of  large  round  cells  with 
intracellular  bridges.  It  was,  therefore,  a  tumor  derived  from  epider- 
mal or  dentine  structures  (Fig.  45). 

After-course. — The  patient  left  the  hospital  at  the  end  of  the  third 
week.  The  wound  was  still  draining  into  the  mouth,  but  granulations 
were  well  started  and  the  opening  into  the  mouth  was  beginning  to 
get  smaller.  He  felt  well  and  had  no  pain.  The  right  side  of  the 
face  in  the  region  of  the  incision  was  just  a  little  larger  than  the 
left.    He  appeared  for  examination  a  year  later  apparently  recovered. 

Comment. — There  is  no  way  of  knowing  how  long  the  tumor  has 
been  developing,  but  most  likely  it  was  the  growth  of  the  tumor  that 
occluded  the  long  existent  drainage  opening.  Though  no  area  could 
be  pointed  to  as  definitely  malignant,  despite  this  a  recurrence  must 
be  expected.  Good  surgery  demanded  the  removal  of  the  entire  supe- 
rior maxilla. 

CASE  6. — A  boy  aged  seven  was  brought  because  of  a  swelling 
of  the  upper  jaw. 

History. — For  three  months  the  mother  has  noticed  that  the  jaw 
was  swollen.  The  lad  seemed  perfectly  well  and  did  not  complain  in 
any  way.     Curiosity,  not  suffering,  caused  them  to  seek  advice. 

Examination. — There  is  a  prominence  of  the  superior  maxilla. 
There  is  no  bulging  of  the  roof  of  the  mouth  and  none  in  the  nasal 
cavity.    The  enlargement  is  painless. 

Diagnosis. — The  painless  origin  suggests  a  malignant  growth.  Sar- 
comas of  the  antrum  are  far  from  uncommon.  Since  there  is  no 
bone  involvement  apparent  a  closer  examination  seems  justified. 

Treatment. — The  upper  jaw  was  exposed  by  a  Weber  incision.  The 
bone  was  opened  with  a  chis:el.     The  cavity  was  found  to  be  filled  with 


DISEASES    OF    THE    PACE    AND    ACCESSORY    SINUSES  107 

a  jelly-like  substance  of  a  pale  straw  color.  After  this  was  removed 
there  seemed  to  be  a  smooth  interior.  An  opening  was  made  into 
the  nose. 

Pathology. — The  material  removed  was  structureless,  there  being 
a  cell  only  here  and  there  with  no  stroma  of  any  sort. 

After-course. — The  patient  was  allowed  to  go  home  after  the  oper- 
ation. When  he  returned  for  a  dressing,  a  quantity  of  sauerkraut 
was  found  between  the  dressing  and  wound.  Quite  a  nasty  suppura- 
tion followed.  An  inch  of  the  alveolar  process  which  became  ne- 
crotic, was  removed.  Save  for  the  loss  of  three  teeth,  recovery 
was  complete. 

Comment. — It  appears  as  though  the  drainage  opening  became  oc- 
cluded and  the  cavity  was  filled  with  mucus  which  had  undergone  a 
thickening  process.  This  looked  like  a  "mucocele"  if  this  name  is 
ever  applied  to  affections  of  this  cavity. 

CASE  7. — A  woman  of  fifty-three  entered  the  hospital  because  of 
a  tumor  of  her  upper  jaw. 

History. — Save  for  poljq^s  removed  from  the  nose  twenty  years 
ago,  there  is  nothing  in  the  history  which  relates  to  the  23resent  trouble. 
A  year  ago  she  had  a  feeling  of  numbness  in  the  side  of  the  face 
and  the  lip  twitched  and  burned.  Four  months  ago  she  noticed  that 
the  nose  was  occluded  sufficiently  to  interfere  with  her  breathing. 
She  consulted  a  nose  specialist  who  removed  a  growth.  This  re- 
lieved her  for  a  few  months,  but  one  month  ago  she  had  the  opera- 
tion repeated,  followed  by  the  use  of  the  cautery.  The  nose  seemed 
to  be  infected  since  and  it  rapidly  refilled.  For  the  past  few  months 
she  has  noticed  the  enlargement  of  the  upper  jaw.  Save  for  a  dis- 
tressing sense  of  fullness,  this  has  not  caused  any  distress.  Ten 
days  ago  she  developed  an  abscess  over  the  sacrum.  This  was  fol- 
lowed by  one  above  the  left  elbow  and  the  right  arm.  The  right  arm 
and  the  feet  have  been  swollen  for  a  week. 

Examination. — The  patient  is  thin  and  anemic  and  shows  a  marked 
enlargement  of  the  left  upper  jaw  (Fig.  46).  The  feet  and  right 
hand  are  edematous.  Added  to  the  prominence  of  the  upper  jaw, 
there  is  a  protrusion  of  a  pinkish  white  mass  which  fills  the  entire 
left  nostril,  bulges  into  the  pharynx,  and  depresses  the  palate.  The 
outer  table  of  the  upper  jaw  is  so  thinned  that  it  crackles  on  pres- 


108 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


sure.     The  Bp.  is  100,  Hg.  40,  W.b.c.  13,000,  Temperature  99  ,  pulse 
84. 

Diagnosis. — The  existence  of  a  nasal  polyp  twent}'  j'ears  ago  and  the 
reappearance  of  a  nasal  mass  in  the  same  region  four  months  ago 
indicates  that  there  may  he  some  relationship.  The  pathologic  states 
■which  develop  the  polyp  likely  formed  the  foundation  for  the  recent 


Fig.    46. — Sarcoma   of  llie   antrum. 

more  rapidly  growing  tumor.  This  would  make  it  likely  that  the 
growth  is  a  sarcoma.  This  is  made  more  likely  by  the  very  rapid 
growth  and  systemic  effect  of  the  growth.  Tiie  pinkish  mass  which 
protrudes  into  the  nose  leaves  little  doubt  of  this.  A  carcinoma  would 
not  be  so  rapid,  would  be  more  dense,  and  temperature  exacerba- 
tion and  leucocytosis  would  not  be  present  unless  there  were  com- 
plications. Occasionally  an  antral  carcinoma  may  so  disturb  the  nu- 
trition of  the  turbinates  that  they  become  edematous  and  pendulous 


DISEASES   OF    THE   FACE   AXD   ACCESSORY    SIXUSES  109 

and  because  of  this  may  be  mistaken  for  protuberant  sarcomatous 
masses.  The  presence  of  leucocytosis  may  cause  sarcomas  in  this  re- 
gion to  be  mistaken  for  empyema  of  the  antrum. 

Treatment. — None.  Because  of  the  extent  of  the  growth  and  the 
general  state  of  the  patient  operation  obviously  was  out  of  the  ques- 
tion. A  small  protruding  mass  was  removed  for  a  section.  In  these 
mucoid  sarcomas  the  x-ray  is  useless. 

PatlioJogy. — The  specimen  is  grayish  and  glistening.  It  is  cellular 
with  many  round  and  few  bipolar  and  stellate  cells. 

Aftet^-course. — The  patient  died  in  six  weeks  of  progressive  ex- 
haustion. 

Comment. — The  tissue  removed  did  not  permit  the  diagnosis  of 
anjd;hing  other  than  a  myxoma.  Nevertheless,  the  clinical  diagnosis 
clearly  was  sarcoma. 

CASE  8. — A  boy  aged  sixteen  was  brought  to  the  hospital  because 
of  a  gTowth  in  his  upper  jaw. 

History.- — Three  years  ago  the  patient  was  "ganged"  by  a  company 
of  hoodlums  and  badly  beaten.  His  upper  jaw  was  particularly 
badly  injured.  A  year  and  a  half  later  it  was  noticed  that  this  side 
of  the  face  was  becoming  larger  and  was  beginning  to  displace  his 
eye  outward.  Nine  months  ago  an  operator  started  to  remove  the 
growth,  but  finding  it  contained  blood,  he  desisted.  Since  then  it  has 
been  growing  more  rapidly  and  has  caused  the  patient  more  pain. 

Examination. — A  tumor  the  size  of  a  fist  occupies  the  upper  jaw. 
The  eye  is  displaced  markedly  outward  and  upward.  The  mass  pro- 
jects into  the  mouth,  displacing  tlie  hard  palate  downward.  The 
mass  is  dense  to  the  touch  and  is  adherent  to  the  skin  of  the  cheek 
along  the  site  of  the  previous  incision.  The  x-ray  gives  the  shadow 
throughout  the  mass  (Fig.  47).  Anteriorly  where  the  incision  had 
previously  been  made  osseous  spicules  show,  a  most  wonderful  ex- 
ample of  the  stimulating  effect  of  cutting  into  a  malignant  tumor. 
The  nasal  walls  are  displaced,  but  not  invaded,  and  there  is  no  evi- 
dence of  increased  vascularity  of  the  soft  parts. 

Diagnosis. — The  density  of  the  tumor  and  the  relatively  slow 
growth  declares  the  elemental  osseous  character  of  the  growth.  The 
mottled  appearance  of  the  x-ray  indicates  the  porosity  which  dif- 
ferentiates it  from  solid  osseous  growths  which  sometimes  develop 
in  the  accessory  cavities.     The   fine   spicules   which   grow   from   its 


110 


("LIXICAL    SIRGERY    BY    CASK    HISTORIES 


surface,  clearly  seen  in  the  x-ray,  indicate  a  sarcomatous  admixture 
to  the  general  bony  character.  The  absence  of  invasion  of  surround- 
ing: tissue,  the  lack  of  dilated  vessels  in  coverinor  soft  parts  and  its 


Fig.  47. — Osteosarcoma  of  the  antrum.  The  area  occupied  by  the  tumor  shows  a  light 
shadow.  The  vertical  spicules  of  bone  seen  on  the  surface  are  characteristic  of  sarcoma. 
The  insert  shows  the  gross  appearance  of  the  tumor  in  situ. 


relatively  slow  growth  indicates  a  low  degree  of  malignancy  which 
warrants  an  attempt  at  operative  removal. 

Treatment. — The  hard  palate  beyond  the  median  line  and  the  max- 
illa, including  the  orbital  plate,  together  with  the  ethmoid  and  part 


DISEASES    OF    THE   FACE    AND    ACCESSORY    SINUSES  111 

of  the  malar  bone,  was  removed.  The  chisel  was  used  throughout. 
This  instrument  is  more  expeditious  than  the  saw.  Save  for  the 
ascending  palatine  artery,  there  was  little  bleeding.  This  was  con- 
trolled with  a  gauze  pack. 

P at Jiologii.— The  mass  was  made  up  of  cancellated  bone  through- 
out, but  considerable  tissue  free  from  bone  could  be  obtained.  This 
showed  small  cells  with  little  intercellular  tissue. 

Afier-course. — Despite  the  large  wound  he  was  able  to  leave  the 
hospital  on  the  eighth  day.  AVhen  last  heard  from,  two  years  after 
the  operation,  he  was  still  free  from  the  growth.    But  it  will  return. 

Comment. — This  tumor  represents  one  of  the  commonest  of  the 
osteomas.  Not  infrequently,  as  here,  there  is  a  history  of  trauma. 
They  rarely  come  to  the  surgeon  until  they  have  been  stimulated  by 
injudicious  tinkering.  Because  of  the  relative  ease  of  their  removal, 
operation  is  justified  but  by  no  means  mandatory.  The  operator  who 
undertakes  their  removal,  however;  must  understand  the  technic  of 
major  surgery  of  the  upper  jaw. 


CHAPTER  IV 

DISEASES  OF  THE  ]MOUTH  AND  JAWS 

Surgical  diseases  of  miieoiis  membranes  are  notewortliy  for  two 
reasons.  Epitlielial  tumors  are  apt  to  be  unusually  malignant  and 
the  triad  of  lesions,  cancer,  syphilis,  and  tuberculosis,  resemble  each 
other  very  closely. 

DISEASES  OF  THE  LIPS 

The  malignant  diseases  of  the  lips  are  well  understood  by  most 
practitioners  botli  as  to  diagnosis  and  as  to  treatment.  The  border- 
land cases  and  a  variety  of  other  conditions  are  less  Avell  understood. 
The  borderland  cases,  particularly,  are  too  often  grossly  mishandled. 
Fissures  and  abrasions  are  too  often  irritated  by  various  local  appli- 
cations. Any  lesion  of  the  lip  should  be  destroyed,  and  there  is  no 
other  region  of  the  body  that  lends  itself  so  well  to  destruction  by 
the  cautery  because  large  defects  are  smoothed  up  to  a  remarkable  de- 
gree by  nature,  so  that  little  or  no  deformity  results.  Fortunately 
most  diseases  of  the  lip  occur  in  men,  in  whom  esthetic  considerations, 
even  to  the  most  artistically  inclined,  need  have  little  weight. 

CASE  1. — A  widow  aged  seventy-two  consulted  me  because  of  a 
blue  spot  on  her  lip. 

History. — The  patient  has  noticed  a  l)lue  patch  developing  in  her 
lower  lip  for  some  months.  There  is  sometimes  a  slight  tingling,  but 
otherwise  she  has  no  sensations.  Her  son,  a  physician,  fears  it  is  a 
melanotic  tumor. 

Examination. — Just  to  the  left  of  tlie  median  line  is  a  bluish  patch 
irregularly  spheroidal  in  outline.  It  lies  beneath  the  mucous  mem- 
brane, and  on  palpating  the  lip,  no  tumor  can  be  felt.  When  the  lip 
is  pressed  upon  by  means  of  a  glass  slide  the  dark  area  disappears. 

Diagnosis. — The  disappearance  on  pressure  proves  it  to  be  vascular, 
and  its  deep  blue  color  indicates  that  it  is  venous.  If  the  area  were 
a  pigmented  tumor  it  would  not  disappear.     I  have  seen  only  one 

112 


raSEASES    OF    TtlE    MOUTH   AND    JAWS  113 

malignant  tumor  in  a  woman's  lip  and  that  was  a  carcinoma  of  the 
upper  lip. 

Treatment. — Owing  to  the  fact  that  microscopic  proof  of  its  benig- 
nancY  was  desired  to  exiiibit  to  anxious  relatives,  the  area  was  ex- 
cised. Otherwise  it  would  have  been  more  convenient  to  plunge  an 
electric  cautery  into  it,  or  still  better  to  have  ignored  its  presence 
entirely. 

Patliology. — The  tumor  is  made  up  of  a  loop  of  a  relatively  large 
vein  and  is  in  every  sense  parallel  to  the  small  circumscribed  vari- 
cosities seen  often  in  the  skin  of  women's  legs. 

After-course. — The  lip  remains  well. 

Comment. — If  the  patient  has  full  faith  in  her  advisor  no  treat- 
ment is  required.  A  surprising  number  of  old  ladies  have  them,  and, 
possessing  the  apprehension  peculiar  to  old  age,  usually  nothing  short 
of  a  demonstration  of  one's  knowledge  by  curing  the  tumors  will 
satisfy  them.  A  few  drops  of  novocain  and  the  plunging  of  a  cautery 
tip  into  them  produces  a  permanent  obliteration. 

CASE  2. — A  merchant  aged  fifty  came  to  the  hospital  because  of 
a  tumor  on  his  lip. 

History. — The  patient  first  noticed  a  purple  spot  on  the  inside  of 
his  loAver  lip  several  months  ago.  He  does  not  know  whether  or  not 
he  injured  it.  It  gradually  became  elevated  and  bled  quite  pro- 
fusely on  a  number  of  occasions.  The  tumor  throbs  sometimes,  but 
gives  no  acute  pain. 

Examination. — To  the  right  of  the  median  raphe  on  the  inside  of 
the  lower  lip  is  a  tumor  the  size  of  a  grain  of  corn.  It  seems  to  ex- 
tend into  the  depth  of  the  lip  so  that  it  has  an  aggregate  size  of  a 
hazelnut.  It  is  bluish  red  in  color  and  blanches  and  becomes  smaller 
when  it  is  pressed  upon  with  a  glass  slide,  but  at  once  resumes  its 
former  state  when  pressure  is  removed.  The  manipulation  incident 
to  this  examination  caused  a  few  drops  of  blood  to  ooze  from  the 
surface. 

Diagnosis. — Its  compressibility  characterizes  the  tumor  as  an  angi- 
oma, a  capillary-venous  angioma. 

Treatment. — The  tumor  was  destroyed  with  an  electric  cauter3^ 

After-course. — There  has  been  no  recurrence  in  four  years. 

Comment. — Excision  might  as  well  have  been  practiced.  The  cau- 
tery, however,  tends  to  obliterate  by  thrombosis  vessels  beyond  the 


114 


(LIXICAL    ST-RGERY    BY    CASE    HISTORIES 


actual  Hue  of  eauterizaticii  and  for  this  reason  is  preferable.     The 
disability  is  less  than  after  excision. 

CASE  3. — A  boy  of  fourteen  was  brought  to  me  because  of  a  thick 
lip. 

History. — The  lip  has  always  been  thick,  but  in  the  past  year  it  has 
increased  in  size.  It  causes  no  inconvenience.  He  desires  to  be 
rid  of  it  because  of  the  taunting  remarks  of  his  school  fellows,  they 
regarding  it,  apparently,  as  an  occupation  hypertrophy. 

Examination. — The  lip  is  three  times  its  normal   bulk    (Fig.  48). 


Fig.   48. —  Lymphangioma  of  the  lip. 


The  color  both  of  tl;e  covering  skin  and  mucosa  is  normal.  It  is  boggy 
and  soft,  but  its  volume  is  not  diminished  by  compression. 

Diagnosis. — The  fact  that  the  lip  can  not  be  compressed  excludes 
hemangioma,  and  the  absence  of  discoloration  confirms  this.  Its  bog- 
gy character  characterizes  it  as  a  lymphangioma. 

Treatment. — He  was  treated  by  x-ray  for  three  sittings. 

After-course. — A  satisfactory  reduction  in  size  followed. 

Comment. — In  adults  x-ray  does  not  give  satisfactory  results  and 
even  in  patients  of  this  age  operation  as  described  in  hemangioma 
gives  more  satisfactory  results.  The  x-ray  was  used  in  this  case  to 
test  the  efficiencv  of  tlie  treatment.     It  often  fails  even  in  children. 


DISEASES    OF    THE    MOUTH   AND    JAWS 


115 


CASE  4. — A  railroad  brakeman  of  twenty-eight  came  to  me  be- 
cause of  a  thick  lip. 

History. — The  patient  has  always  had  a  thick  lip.  He  has  no  dis- 
comfort from  it  except  as  it  offends  his  esthetic  sense. 

Examination. — The  patient  has  a  capillary  ne^Tis  covering  both 
sides  of  his  chin.  The  lower  lip  is  twice  the  thickness  of  its  fellow 
(Fig.  49).  is  soft,  compressible,  and  of  a  deep  wine  color.  It  does 
not  pulsate,  but  when  pressure  is  relieved,  resumes  its  former  size 
instantlv. 


Fig-    49. — Hemangioma   of  the   lip. 

Diagnosis. — The  capillary  angioma  of  the  cheek,  together  with 
the  color  and  compressibility  of  the  lip.  is  sufficient  to  characterize  it 
as  a  caveruotis  venous  angioma. 

Treatment. — A  clamp  was  placed  at  each  angle  of  the  mouth,  the 
blades  extending  outward  and  downward.  A  wedge  of  tissue  was 
removed  from  the  lip,  the  base  representing  half  the  thickness  of  the 
lip  and  the  apex  terminating  at  the  point  where  the  lip  secures  at- 
tachment to  the  jaw.  The  cavity  thus  resulting  was  then  obliterated 
by  placing  a  series  of  four  lines  of  stitures.  the  first  beginning  in  the 
depth  of  the  wound,  and  the  last  uniting  the  mttcous  border.  The 
three  lower  were  of  catgut,  tlie  last  of  horse  hair. 


116 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


PatJioJogij. — The  tissue  removed  presented  the  usual  appearance 
of  a  eavernoma. 

After-course. — Healing  occurred  without  incident.  After  cicatriza- 
tion was  complete,  it  was  found  that  the  lip  was  thinner  than  had 
been  planned  since  the  sutures  caused  obliteration  beyond  the  line  of 
excision. 

Comment. — In  lymphangiomas  the  obliteration  beyond  the  line  of 
excision  dees  not  take  place  but  in  hemangiomas  a  little  allowance 
should  be  made. 

CASE  5. — A  man  aged  thirty-eight  came  because  of  a  scaling  on 
his  lower  lip. 


Fig.    50. — Keratosis    of    the    Idwer    lip. 

History. — For  a  year  and  a  half  a  gradual  roughening  of  the  lower 
lip  has  developed.  It  scales  off  usually  without  pain  or  bleeding. 
Occasionally  the  area  near  the  left  extremity  bleeds  when  the  heavy 
layer  is  picked  off. 

Examination. — The  lip  is  roughened  and  scaly.  The  scales  are  re- 
moved easily  except  near  the  left  end  of  the  lesion,  where  a  little  ooz- 
ing takes  place.  Beneath  this  scaling  area  the  tissues  seem  soft.  The 
whole  process  seems  to  involve  the  epidermal  mucous  layer  only.  (Fig. 
50.) 

Diagnosis. — The  very  superficial  nature  of  the  lesion  seems  to  war- 
rant the  diagnosis  of  a  precancerous  keratosis. 


DISEASES    OF    THE    MOUTH    AND    JAWS 


11' 


Treatment.— The  lesion  did  not  respond  readily  to  the  x-rays  and 
consequently  was  excised  witli  a  margin  of  healthy  tissue. 

Pathology. — There  was  no  tendency  to  epithelial  proliferation 
downward,  no  change  in  cell  type,  but  little  plasma  cell  infiltration, 
and  no  change  in  the  tinctorial  reaction  of  the  connective  tissue. 

After-course. — There  is  no  evidence  of  further  trouble  after  two 
and  a  half  years. 

Comment. — These  lesions  usually  respond  to  the  x-rays.  There 
is  no  apparent  reason  why  this  one  should  not  have  done  so.  Though 
there  was  no  microscopic  evidence  of  malignancy,  I  shall  not  be  sur- 
prised if  this  patient  does  have  future  trouble,  because  the  epithelial 
nuclei  showed  a  well  marked  avidity  for  basic  stains  and  because  of 
the  failure  of  the  lesion  to  respond  to  the  efforts  of  a  competent  roent- 
genologist. 

CASE  6. — A  packing  house  employee  came  to  the  hospital  because 
of  an  ulcer  at  the  anoie  of  his  mouth. 


51. — Trachina  of  the  lip. 


History. — Six  months  earlier  the  patient  noticed  a  small  ulcer 
in  the  angle  of  his  mouth.  It  bled  sometimes  and  interfered  some- 
what with  opening  his  lips.  It  has  developed  slowly  and  the  discom- 
fort is  increasing. 


118  CLINICAL    SURGERY    BY    CASE    HISTORIES 

Examination. — An  ulcer  about  8  by  15  cm.  (Fig.  51)  occupied  the 
corner  of  his  mouth.  The  surface  was  granular,  covered  by  a  crust 
whieli,  when  removed,  caused  bleeding.  The  wall  was  indurated  for 
0.5  cm.  or  more  about  tlie  edge  of  the  ulcer.  The  edges  of  the  ulcer, 
while  hard,  were  not  craterform  and  they  were  rounded  off  and  pre- 
sented evidence  of  attempted  healing.  No  cancer  nests  could  be  ex- 
posed and  none  were  visible.  The  glass  slide  test  failed  to  show  any 
evidence  of  tuberculosis.     There  were  no  palpable  glands. 

Diagnosis. — The  situation  was  noted  as  being  unusual  if  not  unique 
for  carcinoma.  Xo  distinct  cancer  nests  could  be  identified  and  the 
attempts  at  healing  negated  a  primary  epitlielioma.  Tt  was  assumed 
that  the  ulcer  might  have  arisen  from  an  adenoma  which  secondarily 
ulcerated  and  became  malignant.  Nothing  indicated  syphilis,  and  an 
isolated  tuberculous  process  here  seemed  as  unlikely  as  a  carcinoma, 
therefore  a  diagnosis  of  carcinoma  secondary  to  adenoma  was  made. 

Treatment.- — A  wedge-shaped  excision  was  made  including  a  margin 
of  health}'  tissue. 

Pathol ogij. — On  section  nuieh  to  my  amazement  it  was  found  to  be 
a  trachinous  infection  with  no  sign  of  malignancy. 

Com)iients. — This  lesion  shows  the  fallacy  of  being  too  sure  in  diag- 
nosing even  so  simple  a  lesion  as  carcinoma  of  the  lip,  as  well  as  the 
fallacy  of  attempting  diagnosis  by  exclusion.  The  infection  evidently 
Avas  local  for  no  general  manifestations  Avere  noticed.  He  worked 
constantly  with  fresh  pork  but  never  ate  any. 

CASE  7. — A  retired  farmer  aged  sixty-nine  came  to  the  hospital 
because  of  an  ulcer  of  the  lip. 

History. — His  trouble  started  as  a  small  ulcer  of  the  lower  lip  four 
years  ago,  resulting  from  a  small  cut,  and  this  on  healing  first  had  the 
appearance  of  a  small  fever  blister.  It  would  scab  over  and  be  ap- 
parently' healing  but  it  never  entirely  disappeared,  remaining  prac- 
tically stationary  for  three  years.  A  year  ago,  while  working  with  a 
threshing  machine,  the  smut  from  the  wheat  covered  the  ulcer,  caus- 
ing a  great  deal  of  irritation,  and  from  that  time  on  it  grew  rapidly. 
It  was  twice  treated  Avith  a  caustic  paste,  but  after  each  application 
it  failed  to  heal. 

Examination. — The  growth  involves  the  skin  over  the  anterior 
portion  of  the  chin.     The  soft  parts  of  the  chin  are  firmly  attached 


DISEASES    OF    THE    MOUTH   AND    JAWS  119 

to  the  bone.  The  lymph  nodes  under  the  chin  are  noticeably  enlarged, 
but  the  neck  below  the  hyoid  bone  is  free  from  palpable  glands. 

Diagnosis. — Carcinoma  of  the  lip  with  metastasis  in  the  submental 
node  is  the  simple  clinical  diagnosis.  That  the  disease  is  incurable  re- 
quires but  little  more  mental  reservation.  The  area  involved  is  con- 
fined to  the  point  of  the  chin  and  to  the  upper  cervical  triangles.  The 
condition,  therefore,  is  technically  operable.  His  physician  has  con- 
fidenth'  recommended  operation,  and  the  patient  earnestly  desires  it. 

Treatment. — The  treatment  outlined  was  the  blocking  out  of  the 
neck  at  one  sitting  and  a  resection  of  the  chin  two  weeks  later.  As  the 
work  progressed  it  seemed  so  easy  to  finish  that  the  chin,  including 
the  bone  between  the  mental  foramina,  was  resected  and  the  defect 
covered  with  Dieffenbach  flaps. 

Pathology. — The  specimen  presented  a  typical  carcinoma  of  the 
lip  and  lymph  glands. 

After-course. — The  hyoid  bone  being  deprived  of  its  support  by  the 
removal  of  the  chin  allowed  the  larynx  to  drop  back  against  the  pos- 
terior pharyngeal  wall  when  not  supported  by  artificial  means.  A 
loop  of  catgut  was  passed  about  the  hyoid  bone  and  fastened  to  a 
large  dressing  pad.  He  progressed  fairlj^  well  for  some  days,  and 
then  died  of  sepsis  on  the  twelfth  clay  after  the  operation. 

Comment. — A  two-stage  operation  as  originally  planned  would 
not  have  resulted  fatally,  for  the  neck  would  have  been  healed  before 
the  mouth  was  opened  into;  hence  infection  would  have  be?n  avoided. 
This  case  was  operable,  but  not  curable ;  operable  because  all  of  the 
palpable  disease  could  be  excised,  incurable  because  once  the  glands 
of  the  neck  are  involved  in  a  carcinoma  of  the  lip  or  tongue,  cure  is 
out  of  the  question,  in  my  experience,  no  matter  how  radical  the 
operation  may  be.  While  a  period  of  well-being  may  be  secured  the 
patient  by  operation  the  total  duration  of  life  is  not  noticeably  in- 
creased by  it. 

CASE  8. — A  mechanic  aged  thirty-eight  came  to  the  hospital  be- 
cause of  an  ulcer  of  the  lip. 

History. — For  several  years  he  has  had  a  scabbing  on  his  lip.  It 
gradually  developed  into  an  ulcer  which  bleeds  when  the  scab  is  re- 
moved.    He  is  otherwise  well. 


120 


CLINICAL    SURGERY    BY    CASE   HISTORIES 


ExdmiiKition. — An  indurated  nicer  less  than  1  cm.  in  diameter  oc- 
cupies the  vermilion  border  midway  between  the  median  line  and  the 
left  angle  of  the  mouth  (Fig.  52).  The  edges  are  hard,  the  base 
is  granular  and  bleeds  when  pressed  upon.  There  are  no  palpable 
glands. 

Diagnosis. — The  long  history,  the  density  of  the  border,  and  the 
tendency  to  bleed  characterize  it  as  malignant.  It  has  somewhat  the 
feel  of  a  chancre,  but  the  history  is  too  long  and  the  border  is  hard 
instead  of  being  dense  elastic  as  in  the  specific  lesion.  A  chancre 
would  have  inflamed  submental  glands. 

Treatment. — The  growth  was  excised  with  an  electric  cautery  and 
the  deficit  allowed  to  granulate. 


Fig.    52. — Early   carcinoma    of   the   lip. 


PatJioJogij. — Long  columns  of  epithelial  cells  project  into  the  depth 
of  the  tumor.  The  cells  change  their  type  in  the  deeper  portion  and 
they  are  surrounded  by  abundant  round  cell  infiltration  (Fig.  53). 
This  is  sufficient  to  establish  the  growth  as  malignant. 

After-course. — After  the  wound  produced  by  the  cautery  had  com- 
pletely healed,  the  edges  were  freshened  and  the  parts  were  united 
with  silkworm  gut.     He  has  remained  well. 

Comment. — My  experience  with  local  destruction  of  the  tumor  as 
the  first  act  leaving  the  plastic  for  a  second  sitting  has  been  more 
favorable  than  the  radical  block  dissection  for  the  relief  of  or  antic- 
ipation of  metastasis.  The  chief  objection  to  this  plan  is  the  incon- 
venience it  imposes  on  the  patient.     Weeks  are  required  for  recov- 


DISEASES    OF    THE    MOUTH    AND    JAWS 


121 


ery  from  the  cauterization,   and  a  second  visit  is  required  for  the 
plastic  operation. 


Fig.   53. — Karly   carcinoma  of  the  lip. 


DISEASES  OF  THE  TONGUE 


The  single  grave  lesion  of  the  tongue  is  carcinoma.  Whenever  an 
ulcer  of  the  tongue  is  noted,  this  disease  must  be  thought  of,  for  in 
comparison  to  it  all  other  diseases  are  trivial. 


CASE  1. — A  school  boy  aged  seventeen  came  to  the  hospital  be- 
cause of  an  inflammation  of  the  tongue. 

History. — For  four  or  five  years  the  tip  of  his  tongue  has  felt  thick 
and  stiff.  Every  three  to  six  months  it  becomes  markedly  inflamed 
and  remains  so  for  a  week  or  two  and  then  subsides.  On  the  whole 
the  end  is  becoming  larger. 


122 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


Examination. — The  tip  of  tlie  tongue  is  covered  by  fine  translucent 
nodules  for  a  distance  of  two  or  three  centimeters  (Fig.  54).  It  is 
not  much  thickened  as  a  Avhole.  but  there  is  some  bulging.  On  pal- 
pation the  affected  area  is  surprisingly  thickened,  while  the  sur- 
rounding portions  of  the  tongue  are  normally  compressible.  The 
affected  area  feels  nodidar  and  decidedly  dense.  It  is  but  slightly 
sensitive  to  pressure. 

Diagnosis. — -The  translucent  vesicles,  the  nodular  feel,  the  step-like 
growth,  stamp  the  trouble  as  lymphangioma. 


Fig.    54. — Lymphangioma  of  the  tongue. 

Treatment. — An  area  including  the  growth  with  a  margin  of  healthy 
tissue  was  removed.     The  defect  was  closed  by  suture. 

Pathol oejy.— The  nodules  were  formed  by  dilated  lymph  chan- 
nels. They  had  thick  endothelial  linings  and  much  perivascular 
round-cell  infiltration. 

After-course. — There  was  no  notable  defect  in  speech  after  a  few 
months  and  no  recurrence. 

Comment. — When  the  disease  is  confined  to  a  limited  area  of  the 
tongue,  immediate  operation  should  be  done,  for  if  allowed  to  re- 
main, enlargement  will  most  certainly  take  place.  I  observed  a  con- 
dition similar  to  this  twelve  years  ago.  The  patient  refused  operation 
and  by  stages  the  tongue  has  enlarged  until  the  mouth  will  now  hardly 
contain  it.     A   cure   now  would   require  the   removal   of  tlie   entire 


DISEASES    OF    THE    MOUTH    AND    JAWS 


123 


tongue.     Operation  can  not  be  too  strongly  urged  in  these  cases  while 
the  lesion  is  still  small. 

CASE  2. — A  housewife  aged  thirty-six  came  to  the  hospital  be- 
cause of  a  tumor  on  her  tongue. 

History. — The  patient  complains  that  for  six  weeks  she  has  been 


Fig.  55. — Gumma  of  the  tongue. 

developing  a  tumor  in  her  tongue.  There  is  some  dull  pain  and  this, 
together  with  the  size  of  the  tongue,  interferes  with  talking.  She 
has  three  children  apparently  healthy  and  has  had  no  miscarriages. 
Exarnlnaiion. — A  mass  half  an  inch  in  diameter  and  an  inch  long 
occupies  the  substance  of  the  left  half  of  the  tongue.  It  is  fairly 
firm,  tender  to  pressure  and  intimately  attached  to  the  surrounding 
structures.     The  mucous  membrane  is  not  affected.     Further  inspec- 


124  CLINICAL    SURGERY    BY    CASE    HISTORIES 

tioii  discovers  a  periostitis  of  the  medial  half  of  the  clavicle,  also 
of  about  six  weeks'  duration  (Fig.  55). 

Diagnosis. — Owing-  to  tlie  social  surroundings,  it  seemed  safest  not 
to  pry  into  the  personal  history  of  the  patient.  The  tumor  being 
away  from  the  midline,  where  vestigial  tumors  develop,  and  not  being 
a  sarcoma,  even  had  I  obtained  trutliful  replies,  the  information 
would  have  been  quite  superfluous,  for  in  addition  to  the  tongue 
lesion,  there  was  the  unmistakable  periostitis  of  the  clavicle. 

Treatment. — Potassium  iodide  was  given  three  weeks  until  the 
tumor  disappeared,  then  mercury. 

After-course. — The  local  lesion  completely  disappeared.  I  removed 
a  fibroid  of  the  uterus  from  her  ten  years  later.  There  was  no  evi- 
dence of  a  return  of  the  former  disease. 

Comment. — In  patients  of  conspicuous  virtue  of  whom  one  is  not 
warranted  in  suspecting  a  venereal  disease,  I  am  in  the  habit  of 
asking  no  questions  and  am  content  to  prove  my  point  by  therapeutic 
means.  If  the  patient  then  manifests  enough  interest  to  come  down 
on  a  level  on  the  basis  of  facts  revealed,  the  case  is  considered  seri- 
ously from  the  standpoint  of  actual  cure. 

CASE  3. — A  farmer  aged  fifty-six  came  to  the  hospital  because  of 
a  tumor  on  the  base  of  his  tonoue. 

Ilistory. — For  some  time  the  patient  has  felt  a  fullness  at  the  base 
of  the  tongue  when  he  swallows.  He  would  not  venture  to  guess  as 
to  the  duration.  His  consultation  was  actuated  more  by  curiosity 
and  the  thought  of  future  troul)le,  than  by  any  discomfort  he  now 
experiences. 

Examination. — At  the  base  of  the  tongue  is  a  clear  cyst  with  rela- 
tively thick  walls.  It  resembles  a  ranula  save  that  it  is  hemisplierical 
and  the  walls  are  thicker,  and  also  of  course  that  it  is  in  the  wrong 
place.  There  are  no  other  peculiarities  of  the  thyroid  system.  (Fig. 
56.) 

Diagnosis. — Being  situated  at  the  point  where  the  thyroglossal  duct 
originally  enters  the  nioutli,  it  seems  probable  that  it  is  derived  from 
these  structures,  that  is  to  .say,  a  thyroglossal  cyst. 

Treatment. — The  patient  disdained  the  use  of  a  local  anesthetic, 
and  in  accordance  with  his  instructions,  I  grasped  his  tongue  firmly 
with  the  towel-armed  left  hand  while  with  the  right  I  cut  otf  the  top 
of  the  cyst  with  one  swipe  of  a  curved  scissors.     This  left  a  saucer- 


DISEASES    OF    THE    3I0UTH    AND    JAWS 


125 


shaped  area  whicli  was  cauterized  with  lunar  caustic.     The  cut  edges 
of  the  erst  bled  but  little. 

Pafliology. — The  portion  removed  showed  a  fibrotts  walled  cyst 
covered  without  by  a  thin  layer  of  sciuamous  epithelium  and  within  by 
a  columnar  la^-er. 


Fig.    56.^ — Th5-roglossal    cyst    of    the   base    of   the    tongi-.e. 


After-course. — The  cyst  did  not  return,  neither  did  the  patient, 
but  from  relatives  I  learn  that  he  has  remained  free  from  recurrence. 

Comment. — A  more  elegant  treatment  would  consist  in  an  enuclea- 
tion under  local  anesthesia  and  a  closure  of  the  defect.  One  needs 
to  observe  in  these  cases  whether  there  are  other  cysts  more  deeply  sit- 
uated in  the  tongue  or  even  further  down  the  thyroglossal  tract.  There 
seemed  to  have  been  none  in  this  case. 


126  CLINICAL    SURGERY    15Y    CASK    HISTORIES 

CASE  4, — A  physician  ag'ed  forty  came  to  me  because  of  an  ulcer 
near  the  tip  of  the  tongue. 

Histonj. — Several  months  ago  he  noted  a  small  nodule  on  the  left 
margin  of  the  tongue.  This  gradually  enlarged  until  a  small  ulcer 
resulted.  This  was  sensitive  to  food  striking  it.  He  smokes,  but 
there  has  been  no  source  of  irritation.  He  is  a  large,  corpulent  man 
who  has  always  enjoyed  good  health. 

Examination. — The  ulcer  has  a  punched-out  appearance,  the  edges 
are  slightly  overhanging,  show  some  infiltration,  but  they  are  not 
dense.    Other  examinations  are  negative. 

Diagnosis. — This  condition  emphasized  the  difficulty  in  diagnosing 
ulcerous  lesions  of  the  mouth — each  of  the  triad  of  common  diseases 
was  simulated  in  some  degree.  It  had  the  general  appearance  of  a 
tuberculous  ulcer,  but  the  unusual  robustness  of  the  individual  made 
this  seem  unlikely.  So  small  an  ulcer  is  seldcm  seen  in  a  gummatous 
ulceration,  and.  finally,  the  ulcer  was  too  soft  for  carcinoma.  Sad 
experience  has  taught  me  that  beginning  carcinomas  of  the  tongue  in 
3'oung  persons  may  develop  rapidly  and  remain  soft,  therefore,  a  diag- 
nosis of  malignancy  was  made. 

Treatment. — The  gro^\'th  was  resected  and  the  defect  closed  by  su- 
ture. 

Pathology. — The  general  survey  showed  a  generalized  inflamma- 
torj'  mass  and  it  required  a  second  section  to  show  typical  tubercles. 
I  have  found  this  difficulty  in  locating  tubercles  to  be  the  case  in 
tuberculosis  of  the  tongue  quite  generally,  being  true  according 
to  the  acuteness  of  the  process. 

After-course. — Recovery  was  prompt  and  has  remained  so. 

Comment. — The  general  rule  that  tuberculous  lesions  of  the  tongue 
are  found  in  those  who  have  a  like  lesion  of  the  lung  did  not  hold 
in  this  case. 

CASE  5. — A  bookkeeper  aged  fifty-two  came  to  me  because  of  an 
ulcer  on  the  tongue. 

Historg. — His  occupation  has  kept  him  constantly  indoors.  He 
had  had  to  interrupt  his  work  from  time  to  time  because  of  ill  health 
of  an  indefinite  nature.  Fifteen  years  ago  he  spent  some  months  in 
Arizona  because  of  a  persistent  cough.  At  intervals  since  then  he 
has  returned  to  that  climate  when  he  found  he  was  losing  weight.  Ac- 
cording to  his  statement  a  definite  diagnosis  of  tuberculosis  was  never 


DISEASES    OF    THE    MOUTH   AND    JAWS  127 

made.  Six  months  ago  lie  noticed  that  there  was  a  sore  spot  on  his 
tongue  which  soon  manifested  itself  by  a  flat,  wart-like  outgrowth. 
This  has  gradually  increased  in  size  until  it  now  interferes  much  with 
his  taking  food.  He  is  some  20  pounds  under  weight,  hut  he  ascribes 
this  to  his  inability  to  masticate  his  food  properly.  He  has  some  cough 
which  likewise  he  ascribes  to  the  irritation  of  the  growth. 

Examination. — The  patient  is  somewhat  anemic,  has  some  dullness 
and  prolonged  expiratory  sounds  in  the  upper  portion  of  the  right 
lobe.  No  rales  were  heard.  His  sputum  contained  a  few  tubercle 
bacilli.  On  the  left  half  of  the  tongue  from  near  the  dorsum  for 
5  cm.  forward  is  a  fungoid-like  mass  projecting  from  the  surface 
of  the  tongue  about  a  centimeter.  The  surface  was  angular,  papilli- 
form,  moderately  dense,  but  did  not  bleed  on  manipulation.  The 
growth  was  sharply  defined  from  the  surrounding  tongue  tissue  and 
there  was  no  gland  involvement.  The  growth  looked  like  the  fungat- 
ing  carcinomas  of  the  cheek  I  had  seen,  and  a  diagnosis  of  malig- 
nancy was  made  accordingly. 

Treatment. — Resection  of  half  the  tongue  through  a  Kocher  incis- 
ion was  done. 

Pathology. — I  was  confident  of  my  clinical  diagnosis  and  I  demon- 
strated it  as  a  carcinoma  to  my  students.  Sections  were  made  and 
passed  out  to  the  class.  Much  to  my  amazement,  a  delegation  of 
students  promptly  announced  that  the  lesion  was  not  carcinoma  but 
tuberculosis.    They  were  right. 

After-course. — The  wound  healed  promptly,  but  his  cough  increased 
and  despite  a  change  of  climate,  he  died  of  pulmonary  tuberculosis 
some  nine  months  later. 

Comment. — I  had  never  before  seen  a  fungating  tuberculous  process 
of  the  tongue  and  did  not  realize  from  the  descriptions  I  had  read 
that  so  large  a  mass  could  be  produced.  As  a  general  rule  it  may 
be  stated  that  an  individual  suffering  with  tuberculosis  of  the  tongue 
has  a  like  disease  in  his  lung.  And  conversely,  if  an  individual 
has  pulmonary  tuberculosis  and  has  a  lesion  of  the  tongue,  this 
lesion  likely  is  tuberculous  also.  I  have  never  seen  either  carcinoma 
or  syphilis  in  a  patient  affected  with  lung  tuberculosis,  though  no 
doubt  they  do  occur.  Nevertheless,  the  rule  has  stood  me  in  good 
stead. 


128 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


CASE  6. — A  broker  aged  thirty-two  was  sent  to  me  because  of 
a  small  ulcer  on  his  tongue. 

History. — Three  weeks  ago  he  noticed  a  tiny  ulcer  of  the  tongue 
which  has  been  gradually  enlarging.  He  thinks  the  ulcer  was  pre- 
ceded by  a  little  nodule,  but  is  not  sure.  It  is  moderately  painful  to 
contact  with  food.  He  has  never  had  any  other  disorders  about  the 
mouth  and  his  general  health  has  alwa^'s  been  excellent.  The  family 
histoiy  contains  nothing  of  interest. 

Examination. — The  patient  is  an  exceptionally  robust  and  energetic 
young  man.  A  tiny  ulcer  not  more  than  5  or  6  mm.  across  occupied 
tlie  right  margin  of  the  tongue  about  2  or  3  cm.  from  the  tip  (Fig. 
57).  It  was  about  as  deep  as  broad  and  the  margin  was  rather  clear 
cut.  It  was  hard  to  the  touch,  and  the  tiny  white  cancer  nests  could 
be  seen  about  the  border.     One  of  these  was  pressed  out,  flattened 


Fig.    57. — Carcinoma   of  the  tongue. 

on  a  side,  and  the  epithelial  character  of  the  plug  was  demonsti'ated 
by  means  of  a  nuclear  stain. 

Diagnosis. — Carcinoma  of  the  tongue.  The  border  was  dense,  char- 
acteristic of  carcinoma.  This  alone  would  not  have  been  conclusive 
had  not  the  cancer  nests  been  visible  to  the  naked  eye  and  demon- 
stral)le  on  the  slide. 

Treatment. — Half  the  tongue  was  removed  and  a  complete  block 
dissection  of  the  neck  was  done  removing  all  but  the  carotid  vessels 
and  the  nerves  from  the  clavicle  to  the  root  of  the  tongue. 

Pathology. — Section   showed   a   typical   carcinoma. 

After-course. — Notwithstanding  the  very  radical  operation,  recur- 
rence in  the  neck  appeared  in  three  months  and  in  six  the  jDatient  was 
dead. 

Comment. — Carcinoma  of  the  mouth  and  tongue  in  j^oung  persons 
is  a  hoj^eless  disease.     This  case  was  so  earl}-,  having  been  noted  less 


DISEASES    OF    THE    MOUTH   AND    JAWS 


129 


than  a  month  before,  the  general  health  of  the  patient  so  excellent, 
that  I  thought  a  very  hard  try  for  a  cure  was  justified.  I  did  not 
knoAV  then  that  the  very  robustness  of  the  patient  was  an  evil  omen. 
A  skinny,  knockkneed  patient  would  have  stood  a  better  chance.  Now 
instead  of  doing  the  radical  operation  I  did,  I  should  destroy  a  wide 
area  with  the  electric  cautery  in  order  that  he  might  live  his  allow- 
ance undisturbed  bv  anv  extensive  mutilations. 


CASE  7. — A  matron  aged  thirty-five  came  to  the  hospital  because 
of  a  tumor  under  the  tongue. 


Fig.   58. — Sublingual   ranula. 

History. — For  a  number  of  months  she  has  noticed  a  small  tumor 
under  her  tongue.  It  causes  no  pain  but  begins  to  make  its  presence 
known  because  of  its  size. 


130  CLINICAL   SURGERY    BY    CASE    HISTORIES 

Examination. — A  small,  ovoid,  translucent  tumor  occupies  a  posi- 
tion beneath  the  tongue  from  the  middle  of  the  frenulum  extending 
downward  and  backward  to  the  floor  of  the  mouth  (Fig.  58). 

Diagnosis.- — The  position,  in  the  line  of  the  sublingual  duct,  to- 
gether with  its  translucenc}',  stamp  it  as  a  ranula. 

Treatment. — The  major  part  of  the  tumor  was  removed  by  one  snip 
of  the  scissors.  The  interior  of  the  sac  was  then  cauterized  with  a 
stick  of  lunar  caustic. 

Pathology. — The  cyst  was  lined  with  cuboidal  epithelium. 

After-course. — There  has  been  no  recurrence,  notwithstanding  the 
fact  that  this  tongue  has  led  an  exceedingly  active  life. 

Comment. — This  simple  treatment  is  uniformly  effective. 

CASE  8. — A  merchant  aged  fifty-four  came  to  the  hospital  because 
of  pain  in  the  region  of  the  liver  and  loss  of  weight  and  strength. 

History. — Until  four  months  ago  his  general  health  had  always 
been  good.  Since  tliat  time  he  has  had  a  dull  pain  in  the  right  side 
in  the  region  of  the  liver.  His  appetite  remained  good  until  a  short 
time  ago,  but  he  has  lost  ten  pounds  in  the  last  two  weeks.  He  has 
no  special  aversion  to  any  particular  kind  of  food.  His  digestion  has 
always  been  good.  He  has  smoked  heavily  and  has  consumed  much 
beer  but  no  stronger  drinks. 

Examination. — The  patient  is  a  short,  corpulent  man  without  any 
evidence  of  anemia  or  cachexia.  When  asked  to  indicate  the  site 
of  his  pain  he  places  his  open  hand  over  the  lower  part  of  his  right 
chest.  There  is  no  abdominal  tenderness  and  no  rigidity.  The  liver 
dullness  extends  to  the  fourth  rib  but  the  border  moves  on  respiration. 
The  liver  extends  the  breadth  of  two  fingers  below  the  costal  border, 
is  hard,  undulating  but  not  nodular.  The  spleen  is  not  palpable. 
Casual  investigation  discloses  an  ulcer  in  the  midline  of  the  floor  of 
the  mouth  under  the  tongue  (Fig.  59) .  He  was  much  astonished  when 
apprised  of  its  presence  and  had  to  conduct  an  investigation  on  his 
own  account  before  his  credulity  was  satisfied.  The  border  of  the 
ulcer  is  irregular,  hard  and  bleeds  on  touch,  obviously  a  carcinoma. 
Search  in  the  submaxillary  region  fails  to  discover  any  palpable 
glands. 

Diagnosis. — The  liver  is  enlarged  and  hard  without  evidence  of  por- 
tal obstruction  thus  excluding  hepatic  cirrhosis  despite  his  habits.  Its 
densitv  also  is  suggestive  of  malignanev.      There  is  no  reason  to  sus- 


DISEASES    OF    THE    MOUTH   AND    JAWS 


131 


peet  the  stomach  except  on  the  ground  of  general  probability.  There 
is  an  obvious  possible  source  in  the  carcinoma  in  the  floor  of  the 
mouth.  Systemic  metastases  from  these  are  rare,  however,  but  do 
occur.  The  diagnosis  lies  therefore  between  metastasis  from  this 
source,  from  the  gastropancreatic  region,  or  a  primary  tumor  of  the 
liver.    The  first  is  an  obvious  source  but  rare,  the  second  frequent 


Fig.   59. — Carcinoma  of  the  floor  of  t!ie  mouth. 


but  without  evidence  in  this  case,  the  third  gives  the  identical  picture 
here  presented  but  without  evidence  available  for  differential  diag- 
nosis. 

Treatment. — None.  The  ulcer  could  have  been  cauterized  but  the 
gravity  of  the  other  symptoms  was  too  great  to  warrant  it. 

After-course. — The  patient  died  after  about  three  months,  the 
details  of  the  terminal  symptoms  were  not  obtained  other  than  that  of 
progressive  weakness. 


132  t'LlXRAl.    .SIKGEKV    JiV    CASK    HI.STOKIES 

Autopsij. — The  gastropaiicreatic  region  was  free  from  any  disease. 
The  liver  was  occupied  by  ninnerous  tumors  varying  in  size  from  a 
hickory  nut  to  a  small  orange.  The  picture  is  that  of  a  primary  car- 
cinoma of  the  liver.  The  tumor  is  derived  neither  from  hepatic  nor 
bile  duet  epithelium.  The  mouth  remains  the  only  obvious  source 
uf  the  malignancy. 

Comment. — It  seems  strange  that  an  ulcer  the  size  of  this  one  could 
develop  under  the  tongue  without  exciting  the  apprehension  of  the 
patient.  He  has  been  a  saloon  keeper  but  has  quit  the  business,  there- 
fore he  is  a  man  of  some  intelligence.  It  is  not  unusual,  however, 
to  find  cancers  in  the  mouth  which  remain  undiscovered.  The  only 
way  to  exclude  these  things  is  to  carefully  inspect  the  mouth.  In 
obscure  conditions  one  can  well  put  in  his  time  at  such  work  as  this 
while  he  is  thinking.  It  helps  to  cover  up  his  mental  agitation  and 
conveys  the  impression  of  great  thoroughness  instead  of  mental  ob- 
Puscation. 

DISEASES  OF  THE  JAW 

The  important  diseases  of  the  jaws  are  the  malignancies.  The 
ehief  ulcerous  lesion  is  carcinoma.  Actinomycosis,  however,  is  a 
more  common  simulant  than  is  generally  appreciated.  The  connec- 
tive tissue  tumors  are  chiefly  epulides.  Those  of  the  lower  jaw  are 
much  less  malignant  than  like  tumors  of  the  upper  jaw.  The  ex- 
lianding  tumors  of  the  upper  jaw  are  mostly  malignant,  those  of 
the  lower  cystic  or  developmental  anomalies. 

CASE  1. — A  veterinary  surgeon  consulted  me  because  of  a  swelling 
of  his  face. 

History. — Fifteen  months  ago  he  noticed  a  swelling  in  his  lower 
jaw  just  back  of  his  wisdom  tooth.  The  jaw  gradually  swelled  and 
became  painful.  After  nine  months  a  sinus  formed  in  the  skin  just 
above  and  behind  the  angle  of  the  jaw.  A  few  months  later  a  sinus 
developed  an  inch  lower  down  the  neck.  During  the  past  month  the 
temple  has  swollen  markedly  and  he  has  severe  headaches.  He  has 
had  no  other  sickness.  He  has  consulted  a  number  of  surgeons  who 
all  diagnosed  carcinoma. 

Examination. — There  is  an  ulcer  on  the  alveolar  border  extending 
from  the  wisdom  tooth  up  along  the  anterior  pillar  (Fig.  60).  It  has 
an  overhanging  edge  and  a  granular  base.     The  edge  is  very  firm  and 


DISEASES    OF    THE    MOUTH    AND    JAWS 


133 


feels  carcinomatous,  but  on  inspection  there  is  proliferation  of  epi- 
thelium along  the  edge.  The  granular  base  can  be  made  to  bleed 
by  manipulation.  The  bone  is  exposed  at  the  base.  According  to  his 
physician  this  ulcer  has  not  changed  in  the  past  year.  Because  of  the 
pronounced  swelling  of  the  jaw  he  is  unable  to  open  his  mouth  per- 
fectly. The  swelling  of  the  cheek  and  temple  is  so  great  that  the  ear 
is  elevated.  The  eye  is  likewise  encroached  upon.  The  openings  above 
mentioned  are  crateriform  and  puckered  with  scar-like  ridges  leading 


Fig.    60. — Actinoimcosis    of    the   jaw.      (The    artist   failed    to    continue   the    nicer    down    about 

the   wisdom   tooth.) 

out  from  them.  When  the  swollen  area  is  pressed  upon  a  liquid  pus 
exudes,  carrying  with  it  numerous  flakes  of  a  dirty  greyish  white  color. 
The  flakes  showed  filaments  but  no  club-shaped  forms.  Some  of  tlie 
pus  was  injected  into  a  guinea  pig. 

Diagnosis. — While  the  crater-like  openings  were  distinctive  of  actin- 
omycosis, there  were  no  yellow  granules.  Furthermore  the  greyish 
flakes  closely  resembled  those  often  seen  in  tuberculous  pus.  The 
injected  guinea  pig  died  in  thirty  days  and  whitish  nodules  from  2  to 
6  mm.  in  diameter  were  found  on  the  iDeritoneum.     This  was  regarded 


134  CLINICAL    SURGERY    BY    CASE    HISTORIES 

as  confirmatory  evidence  of  tuberenlosis.  It  was  only  after  these 
peritoneal  nodnles  were  sectioned  that  the  fallacy  was  discovered. 

Treaimcni. — General  snppoi'tive  measnres  were  recommended. 

After-course. — The  head  pains  increased  and  he  died  thirty  days 
after  the  first  examination  from  a  gradually  increasing  meningeal 
irritation. 

Comment. — The  local  ulcerous  lesion  together  with  the  swollen 
cheek  with  the  puckered  crater-like  openings  was  pathognomonic.  The 
fetish  of  the  canary-colored  granules  prevented  me  from  making  a 
perfectl,y  obvious  diagnosis.  The  presence  of  the  tubercles  in  the  peri- 
toneum made  the  confusion  complete.  At  the  time  this  patient  was 
observed  none  of  the  inoculation  experiments  had  been  recorded  in 
the  literature.  I  was  not  aware  that  actinomycosis  could  produce 
tubercle-like  lesions.  The  fallacy  was  not  suspected  until  the  lesions 
were  sectioned  as  a  matter  of  routine.  There  are  cases  recorded  iden- 
tical with  this  which  likewise  were  mistaken  for  tuberculosis  because 
of  the  presence  of  greyish  flocculi  and  the  absence  of  yellow  bodies. 
AYhenever  an  ulcer  of  the  jaw  is  accompanied  by  induration  of  tlie 
check,  actinomycosis  must  be  thought  of,  and  if  puckered  crateriform 
openings  are  formed,  the  diagnosis  is  certain,  irrespective  of  the 
character  of  the  pus.  ^Massive  induration  does  occur  in  some  carci- 
nomas of  the  jaw  with  breaking  down  and  the  formation  of  sinuses, 
but  in  these  there  is  no  puckering  about  the  opening. 

CASE  2. — A  man  aged  fifty  came  to  the  hospital  because  of  swell- 
ing of  the  left  side  of  his  face,  pain  and  difficulty  in  opening'  his 
mouth. 

History. — -His  trouble  started  seven  years  ago  when  he  was  struck 
over  the  left  side  of  the  lower  maxillary  bone  by  a  mallet  used  for  driv- 
ing railroad  spikes.  Several  lower  teeth  w^ere  loosened  and  he  bled 
from  the  mouth.  The  pain  never  left,  but  continued  to  grow  worse,  and 
after  two  years  he  had  two  teeth  extracted  from  the  lower  jaw  on 
account  of  the  pain.  The  dentist  said  there  was  necrosed  bone  about 
the  teeth.  An  incision  was  then  made  over  the  left  side  of  the  lower 
jaw  and  the  necrosed  bone  was  removed.  Three  months  later  when 
the  wound  had  not  healed,  he  consulted  a  surgeon  who  called  it  car- 
cinoma and  said  there  was  nothing  to  do  except  to  resect  the  jaw.  He 
consulted  another  surgeon  who  agreed  with  this  diagnosis  and  treated 


DISEASES    OF    THE    MOUTH   AND    JAWS  135 

him  with  radium.  The  wound  healed  apparently  perfectly  after 
four  months  of  radium  treatment. 

He  had  no  further  trouble  until  four  years  later  when  he  had 
swelling  and  pain  over  the  left  antrum.  Two  upper  teeth  began  to 
pain  and  these  were  pulled.  The  dentist  at  that  time  said  he  had 
antrum  trouble.  An  opening  was  drilled  through  the  alveolar  proc- 
ess into  the  antrum  which  was  treated  by  the  dentist  for  a  month. 
The  condition  did  not  improve. 

Examination. — The  patient  presents  an  indurated  swelling  of  the 
left  cheek.  It  is  thickened,  indurated,  almost  hard  to  the  touch  and 
but  little  painful.  It  occupies  the  whole  cheek  from  the  zygomatic 
arch  downward  to  the  upper  part  of  the  neck.  The  whole  cheek  is 
twice  its  normal  thickness.  There  is  an  opening  into  the  antrum  above 
and  behind  the  canine  tooth.  Exposed  spicules  of  bone  present  about 
the  opening.  There  is  no  pus  present.  There  is  no  general  reaction 
of  any  kind. 

Diagnosis. — The  tissues  above  indicated  presented  the  general  ap- 
pearance of  induration.  The  necrosed  bone  seems  to  be  the  cause  of 
the  chronic  irritation.  It  has  all  the  physical  characters  of  a  woody 
phlegmon. 

Treatment. — The  exposed  bone  was  removed.  It  was  nowhere  sepa- 
rated from  the  surrounding  bone.  No  noteworthy  improvement  fol- 
lowed and  he  returned  a  year  later  in  much  the  same  condition.  A 
similar  incision  was  made  and  some  dead  bone  removed  from  the 
alveolar  process  and  a  portion  of  the  hard  palate.  The  cavity  was 
packed  with  gauze,  which  was  removed  on  the  same  day.  No  im- 
provement followed.  He  returned  a  year  later  and  was  operated  on 
again.  An  incision  was  made  straight  back  from  the  left  corner  of 
the  mouth  through  the  cheek.  A  portion  of  necrotic  upper  maxilla 
was  removed  and  the  antrum  found  filled  with  a  myxomatous  looking 
tissue  which  was  curetted  out.  The  cavity  was  packed  with  gauze 
which  was  removed  on  the  following  day. 

Pathology. — It  was  noted  that  the  bone  nowhere  showed  a  disposition 
to  separate  from  the  adjoining  unaffected  bone.  The  soft  tissues 
seemed  to  be  separated  from  the  bone,  like  gums  from  the  teeth  in  py- 
orrhea. The  tissue  gave  the  general  appearance  of  slowly  developing 
granulation  tissue. 

After-course. — The  wound  seemed  to  heal  after  the  last  operation, 
but  it  remained  painful.     The  swelling  was  subsiding  up  to  three 


136 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


weeks  ago  -when  it  started  again.  The  pain  started  in  the  left  ear 
and  along  the  center  of  the  cranium  and  has  be^n  very  severe.  The 
swelling  and  pain  have  been  increasing  ever  since  they  began  three 
weeks  ago.     The  pain  is  steady  and  present  all  the  time. 

The  inside  of  the  mouth  lieah^d  smootlily  with  nothing  to  indicate 
a  new  growth.  The  whole  left  side  of  the  face  was  swollen  like  an  in- 
flammatory process.  The  swelling  now  extended  over  the  temporal  re- 
gion to  the  orbit,  partly  closing  the  eye,  to  well  below  the  jaw.  On  the 
cheek  a  number  of  small  crater-like  openings  presented  which  could  be 


Fig.    61. — Actinomycosis    of    the   jaw    siiowmg    the    crater-like    openings. 

made  to  expel  milkish-white  flocculi  (Fig.  61).  The  true  diagnosis 
now  dawned  on  me  for  the  first  time.  The  greyish  white  nodules  were 
crushed  and  stained  and  the  characteristic  filaments  of  actinomycosis 
readily  demonstrated.  The  indurated  tissues  were  then  injected  with 
Lugol's  solution  and  the  patient  was  given  large  doses  of  potassium 
iodide.  Improvement  began  at  once.  The  process  extended  toward 
the  ear,  however,  and  he  died  six  months  later  of  meningeal  irritation. 
Comment. — It  seems  hardly  possible  that  so  clear  a  history  should 
have  been  overlooked  even  in  the  hurry  of  practice.  The  carious 
bone  following  the  extraction  of  the  teeth  should  have  indicated  the 
truth.    "When  I  first  saw  him  the  ulcerous  le.sion  surrounded  the  area 


DISEASES    OF    THE    MOUTH   AND    JAWS  137 

occupied  by  the  teeth,  the  edge  was  irregular  and  dense  and  bled 
on  manipulation.  The  feel  seemed  entirely  characteristic  of  carcin- 
oma. At  none  of  the  subsequent  operations  was  any  pus  of  any 
sort  observed,  this  in  the  presence  of  alleged  necrotic  bone  should 
have  pointed  the  way,  particularly  since  there  was  no  disposition  of 
the  exposed  bone  to  separate  itself  from  the  unaffected  bone.  As 
"Wright  long  ago  pointed  out,  the  literature  has  too  much  emphasized 
the  yellow  color  of  the  granules.  In  this  case,  as  in  the  most  of  those  I 
have  seen,  the  granules  were  greyish  in  color.  The  failure  to  appre- 
ciate this  led  me  into  an  error  many  years  ago. 

CASE  3. — A  girl  as'ed  fourteen  was  brought  to  me  because  of  a 
hard  growth  on  the  angle  of  the  jaw. 

History. — For  several  years  she  noticed  a  small  tumor  of  the  jaw  on 
the  external  surface  just  above  the  angle.     It  caused  no  pain,  but  it 


Fig.   62. — Exostosis    of   the   lower  jaw.      A.   As   seen   by   the   x-ray.      B.   As   it   appeared   after 

removal. 

was  beginning  to  be  obvious  to  the  public  gaze.  It  had  been  diag- 
nosed as  sarcoma  and  its  removal  by  extensive  jaw  resection  advised. 

Examination. — On  palpation  a  hard,  smooth  mass,  free  from  the 
soft  parts  but  firmly  attached  to  the  jaw  bone,  is  evident.  The  x-ray 
shows  it  to  be  globular  and  dense  throughout   (Fig.  62 A). 

Diagnosis. — Its  sharply  defined  outline  and  smooth  surface  shows 
it  to  be  a  simple  exostosis,  liliely  a  developmental  dentigerous  rest. 
Sarcoma  can  be  ruled  out  because  of  its  smooth  surface  and  constricted 
base. 

Treatment. — An  incision  long  enough  to  admit  a  small  mastoid 
chisel  was  made  well  under  the  margin  of  the  jaw.  The  chisel  was 
introduced  and  the  tumor  cracked  off  at  its  base.  The  tumor  was  then 
shelled  out  with  the  end  of  a  small  scissors  (Fig.  62B). 

Pathology. — The  tumor  was  composed  of  dense  bone  throughout. 


138 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


After-course. — The  incision  after  a  few  weeks  was  quite  invisible. 

Comment. — Bony  tumors  with  constricted  bases  are  presumably  be- 
nign, and  before  disfiguring  operations  are  done  for  their  removal,  all 
factors  in  connection  with  them  should  be  intelligently  reviewed. 
These  dentigerous  outgrowths  occur  most  frequently  on  the  oral  sur- 
face of  the  jaw. 

CASE  4. — A  student  ag-ed  thirty  sought  advice  because  of  a  bony 
prominence  on  his  lower  jaw. 

Historij. — For  as  long  as  he  can  remember  he  has  noted  a  hard  prom- 
inence projecting  from  the  inner  side  of  the  lower  jaw  toward  the 


Fig.    63. — Odontoid    exostoses    of   the    lower   jaw. 


tongue.     It  has  not  grown  and,  aside  from  its  presence,  causes  no 
disability. 

Examination. — A  small  nodule  the  size  of  a  hazelnut  kernel  pro- 
jects inwards  at  the  level  of  the  second  molar  tooth  (Fig.  63).  It  is 
smooth,  possesses  a  covering  of  mucous  membrane,  and  is  extremely 
dense  to  the  touch.     He  has  the  normal  number  of  teeth. 


DISEASES    OF    THE    MOUTH   AND    JAWS 


139 


Diagnosis. — Odontoid  exostosis.  Its  long*  duration  and  fixity  to 
the  jaw  bone  distinguishes  it  from  other  bony  outgrowths. 

Treatment. — It  was  removed  with  a  small  chisel. 

After-course. — Recovery  has  been  complete. 

Commient. — Sometimes  simple  exostoses  occur  about  the  jaw  but 
these  are  usually  on  the  outer  surface. 

CASE  5. — A  farmer  aged  thirty-four  came  for  relief  from  thick- 
ened gums. 


Fig.   64. — Hypertrophy  of  the  gums. 


History. — For  a  number  of  years  the  patient  has  noticed  that  his 
;'ums  were  becoming  thicker.    At  first  the  disturbance  was  slight,  but 


14U  CLINICAL   SURGERY   BY    CASE   HISTORIES 

for  a  year  or  more  mastication  has  been  seriously  interfered  Avitli. 
His  general  health  is  good. 

Exaniinntiou. — Three  teeth  are  absent  on  the  right  side  and  those  on 
the  left  are  not  normally  developed  and  are  irregularly  placed.  The 
teeth  that  are  absent  he  explains  were  removed  because  they  Avere 
decaj^ed  before  the  present  trouble  began.  The  gums  are  so  thickened 
that  they  protrude  nearly  to  the  level  of  the  teeth  and  extend  so  far 
toward  the  median  line  that  they  nearly  touch.  The  thickened  mass 
is  dense,  elastic,  and  has  the  feeling  of  the  harder  varieties  of  keloids. 
(Fig.  64.) 

Diagnosis. — The  uniform  thickening  does  not  correspond  to  any 
definite  tumor,  and  must  be  called,  therefore,  a  hypertrophy.  Epu- 
lides  are  circumscribed  and  always  unilateral.  Cj'sts  sometimes  affect 
both  sides  of  the  jaw,  but  they  are  always  uniform  and  spindleform, 
never  lobulated.  These  masses  are  too  soft  to  be  derived  from  the 
bone. 

Treatment. — The  hypertrophied  ma.sses  were  removed  piecemeal. 
An  area  was  trimmed  down,  and  after  this  had  healed,  another  area 
would  be  treated  in  the  same  way. 

Patho^.ogy. — The  tissue  was  made  up  of  thick  bundles  of  fi1)ers. 
about  a  cross  between  elephantiasis  and  keloid. 

After-course. — Because  of  the  close  histologic  resemblance  to  keloid. 
I  predicted  a  rapid  return,  but  in  this  I  was  happih^  mistaken  for  as 
long  as  a  j'ear  and  a  half  after  operation  no  disposition  to  recur 
renee  was  in  evidence. 

Comment . — The  genesis  of  this  affection  seems  to  be  a  m^'stery. 

CASE  6. — A  business  w^oman  ag-ed  thirty-two  consulted  me  be- 
cause of  swelling-  of  her  gums. 

Ilistorij. — For  some  months  the  patient  has  observed  a  tumor  de- 
veloping back  of  the  incisor  teeth.  It  gradually  extended  until  it 
covered  the  greater  part  of  the  area  of  the  hard  palate.  The  pain 
was  rather  acute  in  the  beginning,  but  now  it  is  dull  with  an  uncom- 
fortable sense  of  pressure.  The  chief  cause  of  complaint  is  inter- 
ference with  mastication.    She  has  never  had  trouble  Avith  her  teeth. 

Examination. — The  tumor  extends  frcm  the  right  lateral  incisor  to 
the  left  bicuspid.  It  extends  backward  halfway  to  the  beginning  of 
the  soft  palate  and  to  below  the  level  of  the  incisor  teeth.  It  is  soft 
and  semifluf'tuatino'.      (Fig.  65.) 


DISEASES    OF    THE    MOUTH    AND    JAWS 


141 


Diagnosis. — The  tumor  lias  the  feel  of  a  lipoma — an  indefinite 
psendofluctuatiou.  Lipomas  do  not  occur  in  this  situation,  however. 
The  mass  shades  gradually  into  the  surrounding  tissue  which  indicates 
an  inflammatory  process.  If  it  were  located  elsewhere  one  would  think 
at  once  of  tuberculosis.    It  is  at  any  rate  a  "cold"  abscess. 

Treatment. — AVhen  cut  into  a  thin  pus  containing  flocculi  like  tu- 
berculous pus  escaped.  The  bone  was  exposed  for  a  considerable 
area,  but  there  seemed  to  be  no  bone  necrosis. 


Fig.    65. — Chronic   abscess   of  the   hard   palate. 


Fatkology. — No  culturable  organism  could  be  obtained.  The  slide 
showed  a  few  cocci  and  many  degenerated  polynuclear  leucocytes. 

After-course. — After  some  months  the  abscess  was  entirely  healed 
and  remained  so  at  least  for  many  years  and  was  well  when  the  patient 
was  last  heard  from. 

Comment. — The  patient  was  a  well-nourished  woman,  little  suggest- 
ing anything  of  a  tuberculous  nature.     The  infection  likely  was  due 


142  CLINICAL    SURGERY    BY    CASE    HISTORIES 

to  an  attenuated  pyogenic  organism.  I  have  repeatedly  seen  smaller 
abscesses  from  near  the  roots  of  decayed  teeth.  These  usually  persist 
until  the  exact  focus  is  eradicated.  None  such  appeared  here  and  it 
may  be  assumed  that  the  infection  gained  entrance  through  the  soft 
parts. 

CASE  7. — A  retired  farmer  ag'ed  seventy-two  came  to  the  hospital 
because  of  an  ulcer  in  his  palate. 

History. — The  patient  had  two  sisters  who  died  of  cancer ;  one  can- 
cer of  the  larynx,  the  other  cancer  of  the  uterus.  A  month  ago  while 
eating  he  bit  his  cheek,  causing  a  sudden  sharp  pain  which  did  not  sub- 
side. He  consulted  a  doctor  who  discovered  a  white  patch  on  the  an- 
terior pillar.  This  was  cauterized.  Despite  this  it  continued  to  spread. 
His  gen;'ral  health  has  always  been  good.  He  uses  tobacco  in  moder- 
ation. 

Examination. — There  is  a  white  patch  on  the  anterior  pillar  extend- 
ing to  the  lower  jaw,  and  over  the  hard  palate.  The  surfac?  of  the 
area  is  soft  but  the  border  is  raised  and  easily  palpable.  The  border 
feels  as  if  a  tiny  string  of  beads  were  embedded  beneath  the  surface 
about  the  border.  The  wisdom  tcoth  is  still  present  and  injures  the 
affected  area  between  it  and  the  plate  of  the  upper  teeth.  The  border 
when  irritated  tends  to  bleed. 

Diagnosis. — Obviously  the  affection  existed  before  the  injury  above 
noted  occurred.  This  event  merely  caused  the  patient  to  seek  advice 
which  led  to  its  discovery.  The  primary  state  may  be  accepted  with- 
out argument  as  leucoplacia.  The  question  of  importance  is  that  of 
possible  malignant  degeneration.  The  raised  border  and  the  disposi- 
tion to  bleed  makes  it  probable  that  a  malignant  change  has  occurred. 
A  piece  removed  for  microscopic  examination  failed  to  show  definite 
signs  of  malignancy  though  there  were  some  changes  in  the  cell 
forms  and  round-celled  infiltration  (Fig.  66-A).  Cauterization  was 
advised,  but  refused. 

A  year  and  a  half  later  he  returned  to  accept  the  treatment  advised. 
During  the  intervening  period  the  lesion  extended  somewhat,  but  the 
chief  changes  were  noted  in  the  border  in  some  areas,  particularly 
over  the  lower  end  of  the  pillar  and  on  the  adjoining  part  of  the 
tongue.  Here  the  border  was  much  raised,  was  dense  and  irregular, 
and  bled  easily  when  manipulated  witli  the  finger.  The  membrane 
was  separating  at  these  points  and  an  ulcer  was  forming. 


DISEASES    OF    THE    MOUTH   AND    JAWS 


143 


Treatment. — Excision  of  the  affected  area  was  done.  Tlie  cheek 
was  split  to  give  access  to  the  affected  region.  The  wound  so  made 
was  closed  bj-  suture. 


vX 


■'■m 


M 

M 

i 

m 


Fig.   66-^4. — Leukoplakia,  benign. 


Fig.   66-B. — Leukoplakia   undergoing   malignancy. 

Pathology. — The  border  excised  showed  a  distinct  tendency  to  in- 
vade the  surrounding  tissue  in  some  regions  (Fig.  66-B)  while  in 
others  the  microscopic  picture  resembled  that  of  a  year  before. 


144 


(lilNlCAL    SlUGEKY    BV    CASK    HISTORIES 


Aftcr-courae. — Healing  was  prompt.  There  was  no  evidence  of  re- 
currence when  the  patient  died  of  cerebral  hemorrhage  three  years 
later. 

Comment. — When  these  leucoplacic  areas  become  malignant,  they 
do  so  slowly  and  a  vigorous  cauterization  at  an  early  stage  may  be 
expected  to  effectualh'  annihilate  them.  Had  I  to  meet  this  indica- 
tion now,  I  should  excise  it  with  an  electric  knife  under  local  anesthe- 
sia. This  would  lessen  the  operative  risk  materially,  besides  making 
the  incision  through  the  cheek  unnecessary.  I  have  employed  this 
means  repeatedly  without  recurrence.  It  is  necessary  to  reach  every 
nook  and  corner.  Because  of  the  extent  of  the  lesions,  this  may  be 
a  very  trying  procedure  both  on  the  patient  and  to  the  operator. 

CASE  8. — A  traveling-  salesman  aged  thirty-eight  came  to  the 
hospital  because  of  a  thickening  of  his  lower  jaw. 

Hisionj. — The  patient  noticed  for  several  years  that  the  left  side  of 
the  lower  jaw  was  beccming  thickened.     It  was  painless  and  until  it 


Fig.   67. — Dentigerous   cyst   of   the   lower  jaw. 


became  great  enough  to  bulge  the  side  of  the  cheek  he  neglected  it. 
Now  he  seeks  relief  from  the  deformitv. 


DISEASES    OF    THE    MOUTH   AND   JAWS  145 

Examination. — There  is  a  spindleform  enlargement  on  the  external 
surface  of  the  jaw  beginning  at  the  mental  foramen  and  terminating 
at  a  centimeter  or  two  in  front  of  the  angle.  At  its  highest  point  it 
attains  an  elevation  of  about  2  cm.  It  is  smooth,  hard,  and  painless. 
The  inner  surface  of  the  jaw  is  not  affected.  The  mucous  membrane 
is  movable  over  most  of  its  extent.  The  bone  can  not  be  indentated 
by  pressure.     There  are  no  teeth  missing.      (Fig.  67.) 

Diagnosis. — The  slow  growth  stamps  it  as  benign.  It  is  evidently 
connected  with  the  bone.  Solid  bony  tumors  are  usually  globular,  the 
spindleform  are  usually  cystic,  combined  osseous  and  cystic  are  irreg- 
ular globular.     This  one  must  therefore  be  cystic. 

Treatment. — The  surface  was  infiltrated  with  novocain  and  the 
inferior  maxillary  nerve  was  blocked  at  the  lingula.  The  mucous 
membrane  was  incised  along  the  most  prominent  part  and  the  peri- 
osteum deflected.  The  shell  was  opened  with  a  mastoid  chisel.  The 
excess  of  bony  capsule  was  excised  with  a  small  rongeur.  That 
portion  of  the  cyst  wall  nearest  the  jaw  was  curetted.  The  deflected 
periosteal  mucous  flaps  were  then  pressed  into  the  opening  and  held 
there  by  a  tampon. 

Pathology. — The  shell  was  composed  of  normal  bone,  the  lining 
of  squamous  cells.    There  were  no  giant  cells. 

After-course. — More  or  less  infection  took  place  and  some  six  weeks 
were  required  before  the  lesion  was  healed. 

Comment. — Such  simple  treatment  is  always  sufficient  for  this  con- 
dition. These  cases  are  often  subjected  to  needlessly  radical  oper- 
ations. 

CASE  9. — A  man  aged  sixty  came  to  me  because  of  an  ulcerated 
condition  in  the  roof  of  his  mouth. 

History. — For  six  months  he  has  had  ulcers  in  the  roof  of  his  mouth, 
extending  more  or  less  over  both  the  hard  and  soft  palates.  He  states 
that  a  Wassermann  has  been  made  which  was  negative,  but  despite 
this  his  physician  gave  him  several  doses  of  salvarsan,  but  no  im- 
provement has  resulted.     The  general  history  is  not  illuminating. 

Examination.- — The  patient  seems  a  man  in  good  health.  Save  for 
the  roof  of  his  mouth  he  has  no  lesion  of  any  sort.  The  site  of  com- 
plaint presents  an  uneven  surface,  resembling  pictures  of  fields  torn 
by  shells.  There  seems  to  be  no  regularity  except  about  the  border, 
where  a  reniform  outline,  both  of  the  individual  lesion  and  the  com- 


146 


CLINICAL    SURGERY    BY    CASE   HISTORIES 


posite  arrangemeut,  can  be  made  out.  Some  areas  have  healed.  Those 
still  iu  a  state  of  ulceration  present  sharp,  slightly  undermined,  fairly 
soft  borders.  The  soft  palate,  as  well  as  the  hard,  is  affected.  No- 
where is  there  a  complete  perforation.  The  pillars  and  pharyngeal 
walls  are  not  affected.     (Fig.  68.) 

Diagnosis. — The  outline  of  the  lesions  and  the  type  of  ulceration 
is  distinctive  of  syphilis,  and  this  diagnosis  must  be  maintained  de- 
spite the  serum  reaction  and  therapeutic  test.  The  soft  character 
of  the  tissue  and  the  tendency  to  heal,  together  with  the  superficial 


Fig.  68. — Syphilitic  ulceration  of  the  palate. 


character  of  the  lesion,  excludes  carcinoma.  Tuberculosis  is  more  apt 
to  attack  the  pillars  or  pharyngeal  wall,  but  it  does  not  produce  the 
regular  outlines  found  in  this  case. 

Treatment. — The  vigorous  prosecution  of  the  antisyphilitic  treat- 
ment was  advised. 

After-course. — Complete  healing  took  place  after  several  months' 
treatment  with  mercury  and  has  remained  so. 

Comment. — "When  the  clinical  character  of  a  lesion  speaks  pro- 
nouncedly for  syphilis,  the  therapeutic  test  may  be  pushed  to  an 
extreme  degree.  I  have  seen  lesions  respond  after  750  grains  of  po- 
tassium iodide  were  used  over  a  period  of  several  weeks  when  doses 


DISEASES    OF    THE    MOUTH   AND    JAWS 


147 


of  half  this  amount  failed  to  make  an  impression  after  being  given 
for  weeks. 

CASE  10. — A  housewife,  aged  forty-six,  came  to  the  hospital  be- 
cause of  a  tumor  of  the  upper  jaw. 

History. — The  patient  has  observed  the  formation  of  a  tumor  on  her 
gums  for  four  years.    It  has  not  caused  any  pain,  neither  has  it  bled. 


Fig.  69. — Epulis  of  the  upper  jaw. 

but  its  size  begins  to  aimoy  her  and  its  esthetic  effects  were  quite 
unsatisfactorj'  to  her.     She  has  had  no  trouble  with  any  of  her  teeth. 

Examination. — A  bluish-red  tumor  the  size  of  a  walnut  occupies 
the  external  surface  of  the  alveoli  corresponding  to  the  incisor  and 
canine  teeth.  The  tumor  is  smooth  and  covered  everywhere  with 
mucosa.  It  is  constricted  at  its  base  and  can  be  moved  about  some- 
what.    (Fig.  69.) 

Diagnosis. — Its  site,  consistency,  and  covering  of  mucosa  identifies 
it  as  an  epulis. 


148  cUMCAi,  sik(;i;kv   I'.v  cask  hirtorikr 

Treatment. — The  gingival  mucosa  was  cut  through  to  the  bone  both 
external!}^  and  internally,  well  away  from  the  base  of  the  tumor.  The 
alveolar  process,  together  with  incisor  teeth,  was  removed  with  a 
large  cutting  forceps.  The  exposed  bone  was  cauterized  witli  iodine, 
and  the  wound  packed  to  control  oozing  from  the  bone.  The  ojjera- 
tion  was  done  under  local  anesthesia. 

Pathology. — The  tumor  is  a  giant-celled  sarcoma. 

After-eovrsr. — The  wound  lioalod  oxov  and  has  remained  a  smootli 
scar. 

Comment. — Had  the  patient  been  more  subservient  to  suggestion,  I 
should  have  cut  the  tumor  from  the  bone  with  the  knife  blade  cautery, 
extracted  tlie  tooth  and  then  have  cauterized  the  socket.  This  would 
have  left  an  alveolar  border  which,  with  a  bridge  across  the  toothless 
space,  would  have  left  no  deformity. 

Epulides  with  a  broad  base  of  attachment  along  the  alveolar  process 
are  more  malignant  and  do  not  lend  tliemselves  to  such  conservative 
treatment.  Fortunately  they  are  usually  situated  farther  back,  and 
tlie  removal  of  the  alveolar  process  does  not  cause  so  much  deformity. 

CASE  11. — A  boy  aged  eight  was  brought  to  me  because  of  a  tumor 
of  the  gums. 

History. — Nine  months  ago  it  was  noticed  that  the  lad  was  develop- 
ing a  tumor  of  the  gums  of  the  upper  jaw.  Three  months  ago  it  was 
removed  by  the  family  doctor.  It  returned  promptly,  and  now  is 
larger  than  before  the  operation. 

Examination. — Going  out  from  the  region  of  the  canine  tooth  of  the 
right  upper  maxilla  is  a  tumor  the  size  of  a  hickory  nut  (Fig.  10-A). 
It  is  irregularly  lobulatcd  and  surrounds  the  canine  and  bicuspid 
teeth.  It  is  dense  to  the  touch  and  covered  with  mucosa  except  in 
two  places  where  a  red  fibrous  mass  seems  to  be  forcing  itself  through 
the  covering.  The  base  of  the  tumor  is  sharply  defined  from  the 
gums. 

Diafjnosis. — Its  density  and  the  fact  that  the  covering  epithelium 
is  unaffected  indicates  that  it  is  an  epulis.  It  is  too  firm  for  a  granu- 
loma and  too  large.  It  is  too  sharply  defined  to  suggest  a  periosteal 
sarcoma. 

Treatment. — The  alveolar  l)order,  together  with  the  teeth,  was  re- 
moved (Fig.  70-7?). 


DISEASES    OF    THE    MOUTH    AND    JAWS 


149 


Pathology. — The  tumor  is  made  up  of  fibrous  tissue  without  giant 
cells. 

After-course. — The  patient  remained  well. 

Comment. — Epulides  are  ordinarily  semibenigu  tumors,  but  fre- 
quentlr,  when  incompletely  removed,   they  show  great  malignancy, 


Fig.    70. — A.      Epulis   of   the   upper  jaw   after   removal.      B.  Epulis    of   the    upper   jaw    before 

removal. 

particularly  those  without  giant  cells.  Usually  the  teeth  affected 
must  be  removed  to  the  base  of  their  sockets.  However,  the  small 
ones  arising  from  the  surface  of  the  gums  may  be  destroyed  with  a 
eauterv  and  the  teeth  saved. 


CASE  12.— A  farmer  aged  thirty-nine  came  to  the  hospital  be- 
cause of  a  tumor  of  the  left  upper  jaw. 

History. — The  patient  fii-st  noticed  a  slight  swelling  of  the  gums 
outside  of  the  left  eye  tooth  three  years  ago.  It  remained  stationary 
about  a  year,  and  then  started  to  grow.  At  the  end  of  the  first  year 
his  dentist  curetted  the  enlargement  frcm  the  gum  and  from  around 
the  tooth  roots.  It  remained  away  for  six  months  then  started  to 
grow  again  and  was  curetted  once  more  and  burned  with  acid  three 
times.  In  the  last  three  months  it  has  grown  rapidly  and  the  en- 
largement could  then  be  noticed  from  the  outside.  It  never  gave 
any  pain  until  the  last  few  months,  when  a  disagreeable  sensation 
was  noticed  over  the  cheek  bone.    It  has  never  bled. 

Examination. — A  tumor  is  seen  extending  from  the  alveolar  process 


150 


CLINICAL    SURGERY    BY    CASE   HISTORIES 


ill  the  region  of  the  bicuspid  and  molar  teeth  on  the  left  side  (Fig.  71). 
The  surface  is  smooth  and  is  entirely  covered  by  epithelium.  Bosse- 
lated  borders  widen  the  alveolar  border  half  a  centimeter  on  either 
side.  It  does  not  seem  to  extend  into  the  antrum.  There  is  no  other 
evidence  of  involvement. 

Diagnosis. — The  growth  is  obviously  an  epulis.  It  seems  confined 
to  the  immediate  environs.  The  patient  is  very  desirous  that  removal 
be  effected  without  making  an  incision  through  the  cheek.  The  growth 
is  so  well  confined  that  local  resection  seems  warranted. 

Treatment. — The  growth  was  removed  under  local  anesthesia,  with 


/ 


1 


Fig.  71. — Epuli 


a  considerable  free  margin,  through  the  mouth.  The  antrum  was 
opened  into  for  an  inch  or  more. 

Patholo(j!j. — The   slide   shows   the   usual   giant-celled   sarcoma. 

After-course. — The  wound  healed,  but  in  less  than  a  year  extensive 
involvement  of  the  upper  jaw  had  taken  place.  A  complete  resection 
of  the  upper  jaw  was  then  done  but  without  avail.  The  growth  re- 
turned and  caused  his  death  a  year  later. 

Comment. — Wlien  a  surgeon  approaches  a  malignant  growth  he 
should  be  deaf  to  sentiment.  A  resection  of  the  entire  superior  max- 
illa in  the  first  place.  I  have  no  doubt  would  have  resulted  in  a  cure. 
Once  an  epulis  has  recurred,  further  temporizing  is  not  permissible. 


DISEASES    OF    THE    MOUTH    AXD    JAWS 


151 


This  is  one  tumor  that  is  curable,  aucl  if  its  cure  is  not  accomplished 
the  plans  must  have  gone  awry  somewhere. 

CASE  13. — A  school  teacher  aged  forty-two  came  because  of  a 
tumor  of  the  giims. 

History. — For  three  months  she  has  noticed  a  small  tumor  growing 
between  two  of  her  front  teeth.  It  has  not  been  painful,  but  sometimes 
it  bleeds.    Her  doctor  removed  a  part  of  it  and  sent  it  to  a  professor  of 


Fig.  72. — Granuloma  of  the  alveolar  border. 

pathology  in  a  neighboring  state  who  returned  a  report  of  a  small 
round-celled  sarcoma.  On  the  basis  of  this  she  comes  to  have  a  re- 
section of  the  jaw.    Her  health  is  good. 

Examination. — Between  the  canine  and  bicuspid  teeth  is  a  deep 
red  fungus-like  tumor  the  size  of  two  grains  of  corn.  It  is  soft  and 
compressible,  but  quickly  regains  its  form  when  pressure  is  relieved. 
Its  base  occupies  the  space  between  the  teeth  and  about  their  roots. 
Bleeding  follows  the  attempt  to  determine  the  extent  of  its  attach- 
ment.    (Fig.  72.) 


152  CLINICAL    SURGERY    BY    CASE    HISTORIES 

Diagnos'S. — It  is  too  soft  and  bleeds  tco  readily  to  ba  an  epulis. 
Furthermore,  epulides  do  not  develop  so  rapidly.  Its  rapid  growth, 
its  vascularity  and  its  tendency  to  bleed  stamp  it  as  a  granuloma.  Sar- 
coma it  most  certainly  is  not.  Small  round-celled  sarcomas  of  the 
jaw  are  very  rare  and  they  involve  a  greater  space. 

Treatment. — The  growth  was  cut  off  with  a  cautery  knife  blade 
and  the  site  of  origin  carefully  cauterized.    The  teeth  were  not  pulled. 

Pathology. — The  tumor  is  made  up  of  small  round  cells  with  round 
nuclei  and  sparse  protoplasm,  together  with  many  polynuclear  lym- 
phocytes. The  whole  is  interspersed  with  bundles  of  fibrous  tissue. 
The  connective  tissue  was  small  in  amount  and  interspersed  between 
the  cells. 

After-course. — Healing  was  prompt  and  permanent. 

Comment. — The  error  here  was  possible  because  the  pathologist 
attempted  to  make  a  diagnosis  on  the  microscopic  picture  alone.  Xot 
infrequently  granulation  tissue  simulates  sarcoma  and  the  clinical 
history  must  be  taken  into  account. 

CASE  14. — A  boy  aged  s^x  was  brought  because  of  a  tumor  of 
his  upper  jaw. 

History. — AYhen  the  ehild  was  four  years  old  it  was  noticed  that  a 
tumor,  half  the  size  of  a  grain  of  corn,  had  appeared  about  the 
root  of  his  first  double  tooth.  A  dentist  destroyed  this,  but  it  soon 
returned.  Six  months  later  he  was  given  an  anesthetic,  the  tooth 
was  extracted,  and  the  groAvth  again  destroyed.  Still  six  months 
later  the  growth  again  appeared  and  has  grown  gradually  since.  He 
is  well  otherwise  and  the  growth  do?s  not  seem  to  inconvenience  him. 

Exnnibmtwn. — There  is  a  growth  extending  from  the  canine  to 
the  last  molar  tooth.  It  represents  a  roundish  roll  something  more 
than  half  an  inch  in  diameter  (Fig.  73-A).  The  growth  seems  to 
elevate  the  mucosa  of  the  hard  palate  to  near  the  median  line.  It  is 
covered  with  epithelium  and  is  of  a  bluish  red  color.  Pressure  causes 
but  little  pain.    The  growth  has  a  generally  firm  elastic  feel. 

Diagnosis. — The  tumor  evidently  is  an  epulis.  The  problem  is 
how  extensive  an  operation  should  be  done.  The  second  operation, 
if  properly  done,  sliculd  have  resulted  in  a  cure.  That  it  did  not  and 
because  there  is  apparently  an  extension  across  the  hard  palate,  in- 
dicates that  this  growth  is  not  to  be  trifled  with.  Therefore  a  radical 
resection  of  the  jaw  may  well  be  advised. 


DISEASES   OF    THE    MOUTH   AND    JAWS  153 


Fig.    7i-A. — Epulis  of  the   upper  jaw  which  has  extended  to   the  antrum  and   across   the  hard 

palate. 


Fig-.    73-B. — Slide    of    the    preceding    showing    typical    giant  celled    sarcoma. 

Treatment. — A  resection  of  the  superior  maxilla  was  done  going  a 
little  beyond  the  median  line  in  the  hard  palate  but  leaving  the 
floor  of  the  orbit  and  the  malar  articulation. 

Pathology. — The  tumor  is  a  typical  giant-celled  sarcoma  (Fig. 
73-5). 


154  CLINICAL    SURGERY   BY    CASE    HISTORIES 

After-course. — Eecovery  was  prompt  and  complete  and  remained 
so. 

Comment. — Evidently  neither  of  the  first  operations  reached  the 
full  extent  of  the  growth.  It  cannot  be  too  often  repeated  that 
giant-celled  epnlides  of  the  jaw  tend  more  to  recurrence  than  tumors 
of  like  structure  and  extent  situated  ou  the  lower  jaw.  Had  this 
tumor  not  been  previously  operated  on,  or  had  but  a  superficial  opera- 
tion been  done,  I  should  have  been  more  conservative.  Once  an 
operation  has  been  done,  which  may  have  entered  the  antrum,  noth- 
ing short  of  a  complete  resection  of  the  jaw  is  warranted. 

CASE  15. — A  farmer  aged  sixty-four  came  to  the  hospital  because 
of  a  tumor  of  his  jaw. 

Hist  or;/. — Four  years  ago  he  noticed  a  tumor  on  the  gums  of  his 
upper  jaw.  It  was  scraped  off  and  burned  by  his  dentist.  It  began 
to  grow  after  a  few  months  and  has  continued  to  enlarge  to  tlie 
present  time.     Only  in  the  past  two  months  has  it  caused  any  pain. 

Examination. — A  tumor  as  large  as  a  hulled  walnut  occupies  the 
alveolar  Ijorder  and  hard  ]ialate  of  the  right  upper  jaw.  It  is  red- 
dish blue  in  color,  the  surface  smooth  and  the  consistency  firm.  It 
seems  sharply  defined  and  the  antrum  seems  free.  The  chest  is 
emphysematous  and  otherwise  general  examination  is  negative.  (Fig. 
73-C). 

Diagnosis. — The  slow  growth,  the  color,  the  firmness  characterize 
it  as  an  epulis.  The  patient  is  a  fairly  well  preserved  man  but  shows 
some  evidence  of  recent  emaciation.  The  ]iatient  seems  but  a  fair 
risk  and  he  fears  an  operation.  Under  local  anesthesia  a  resection 
of  the  upper  jaw  seems  a  good  risk  and  the  prospects  of  a  cure  seem 
excellent. 

Treatment. — Before  operation  was  begun  a  chain  of  lymph  glands 
were  discovered.  They  were  smooth  and  hard  and  fairly  movable. 
Considering  the  unwillingness  of  the  patient  to  stand  his  share  of  the 
responsibility,  operation  was  refused. 

Affer-conrse. — The  progress  continued  unabated,  the  glands  of  the 
neck  assuming  the  ascendency. 

Comment. — The  lymphatic  involvement  was  overlooked  at  the  first 
examination.  An  operation  was  technically  possible  and  had  the  pa- 
tient been  willing  to  accept  the  best  surgery  had  to  offer  I  should 


DISEASES    OF    THE    MOUTH    AXD    JAWS 


155 


have  been  willing  to  attempt   an  operation.     It  is  unusual  to  find 

lymph  gland  involvement  in  these  tumors. 


Fig.  ll-C. — Large  epulis  of  the  upper  jaw  involving  the  alveolar  border  and  the  hard  palate. 


CHAPTER  V 

DISEASES  OF  THE  NECK 

Diseases  of  the  neck  are  niultitiulinous  and  important.  A  greater 
variety  of  tumors  are  encountered  here  than  in  any  other  region  of 
the  body.  Inflammatory  affections  of  the  neck  are  sometimes  difficult 
to  sejoarate  from  true  tumors.  The  various  types  of  tumors  may  be 
separated  only  with  difficulty.  The  surgeon  must  always  anticipate 
the  worst  and  proceed  with  caution. 

LYMPHATIC  TUMORS  OF  THE  NECK 

Tumorous  enlargements  of  the  lymph  glands  of  the  neck  are  pre- 
sumably malignant.  It  requires  painstaking  consideration  of  all  the 
clinical  signs  in  many  instances  to  arrive  at  a  positive  opinion.  Even 
witli  every  care  time  alone  in  some  instances  can  render  a  positive 
verdict.  Excision  of  a  gland  for  the  purpose  of  making  a  microscopic 
diagnosis  is  not  justified.  Too  often  even  with  this  aid  the  diagnosis 
remains  uncertain  and  at  best  the  disease  is  stimulated  to  renewed 
activity  if  it  is  malignant. 

CASE  1. — ^A  widow  aged  eighty-two  came  to  the  hospital  because 
of  a  tumor  under  her  ear. 

History. — Two  months  ago  the  patient  noticed  a  tumor  developing 
on  the  neck  below  the  right  ear.  It  was  painful  from  the  start  and 
the  summit  soon  became  red  and  soft.  Her  doctor  believing  it  was 
an  abscess  incised  it.  Failing  to  secure  anything  but  a  free  hemor- 
rhage he  sent  her  to  the  hospital. 

Examination. — Just  behind  the  posterior  border  of  the  sternomas- 
toid  near  its  insertion  is  a  pyramidal  shaped  tumor  the  size  of  an 
unhulled  walnut.  The  surface  is  reddened  and  soft  and  from  a  small 
incision  at  the  apex  a  thin  bloody  ichorous  discharge  is  escaping.  The 
remainder  of  the  tumor  below  the  soft  apex  is  firm  but  elastic.  It 
moves  slightly  laterally  with  the  underlying  tissues  but  is  iimnovable 


DISEASES   OF    THE   NECK  157 

upward  or  clowmvard.  There  are  uo  palpable  glands.  The  patient's 
general  health  is  unimpaired. 

Diagnosis. — This  tumor  springs  from  the  deep  structures,  obviously 
from  the  posterior  hinpliatics.  Its  rapid  enlargement  and  solitary 
character  suggests  a  lymphosarcoma.  It  is  obviously  not  inflamma- 
tory. The  absence  of  other  lymphatic  enlargement  excludes  Hcdg- 
kin's  disease.  From  abscess  it  may  be  distinguished  since  abscess 
never  is  so  circumscribed  in  proportion  to  its  height.  Abscesses  when 
they  become  fluctuant  are  so  in  their  center  while  in  these  tumors  the 
pseudo-fluctuating  area  is  confined  to  the  apex. 

Treatment. — Xone.  The  x-rays  would  have  been  used  had  they 
been  available. 

After-course. — A  fungating  mass  soon  appeared  in  the  opening 
and  rapidly  enlarged  it.  In  a  few  weeks  a  large  fungiform  mass 
covered  the  whole  summit  of  the  tumor.  This  was  associated  with  a 
rapid  enlargement  of  the  tumor  in  all  directions.  The  patient  died  in 
two  months. 

Comment. — I  have  observed  a  number  of  instances  in  which  these 
tumors  were  opened  into  under  the  impression  that  they  contained 
pus.  The  result  is  always  that  a  fungating  mass  appears  and  the 
tumor  is  stimulated  to  more  rapid  growth.  The  ulcerating,  secreting 
mass  is  annoying  both  to  the  patient  and  to  the  attendant  who  incised 
it. 

CASE  2. — A  widow  aged  seventy  came  to  the  hospital  because  of 
a  tumor  on  her  neck. 

History. — For  a  year  a  tumor  has  been  developing  under  the  angle 
of  her  jaw.  Recently  it  has  been  enlarging  more  rapidly  until  it  has 
attained  its  present  size.    Otherwise  she  has  always  been  well. 

Examination. — The  patient  is  an  unusualh*  well  preserved  old  lady. 
She  has  a  tumor  the  size  of  a  lemon  over  the  sternomastoid  process 
(Fig.  74).  It  is  smooth  and  elastic  and  is  movable  slightly  laterally 
but  not  vertically.  It  is  attached  to  the  deeper  tissue  but  can  not 
be  made  to  protrude  into  the  mouth.  There  are  no  other  tumors  palpa- 
ble. 

Diagnosis. — Being  solitary  and  elastic  in  this  situation  attached  to 
the  deeper  tissue  indicates  its  origin  from  the  lymph  gland.  The 
blood  examination  being  without  change,  this  must  be  a   localized 


158 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


Hodgkiu's  or  a  Ij-mphosareoma.  Because  it  is  solitary  it  is  best 
placed  with  the  lymphosarcomas. 

Treatment. — The  x-rays  were  recommended  but  the  advice  was  not 
followed. 

After-course. — The  patient  remained  in  much  the  same  state  for 
nearly  a  year  with  but  little  change  in  the  outlines  of  the  tumor. 
At  about  this  tinu^  she  began  to  have  attacks  of  dyspnea  and  some 


J"ig.   74. — Lymphosarcoma  of  the   neck. 


digestive  disturbance  and  she  lost  weight  rapidly.  She  died  four 
months  later  with  gradually  increasing  weakness. 

Autopsy. — The  mediastinum  and  the  retroperitoneal  glands  were 
as  large  as  potatoes  compressing  the  adjacent  tissues.  The  slide  showed 
lymphoid  cells  with  a  small  amount  of  reticulum. 

Comment. — The  lymphatic  tumors  when  they  remain  solitary  for  a 
long  time  are  usually  regarded  as  lympliosarcomas :  when  multiple,  as 


DISEASES    OF    THE   NECK 


159 


Hodgkin's.  In  structure  the  chief  difference  lies  in  the  fact  that  in 
Hodgkin's  eosinopliiles  and  endothelial  cells  are  often  much  increased. 
Wlien  these  are  absent  there  is  no  definite  mark  of  distinction. 

CASE  3. — A  merchant  ag'ed  forty-two  came  to  the  hospital  because 
of  recurrent  tumors  of  the  neck. 

History. — Three  years  ago  he  noticed  a  tumor  develoj)ing  under 
the  angle  of  his  jaw.     This  was  soon  followed  bv  others.     He  con- 


Fig.    75. — becondary   nodule   in   Hodgkin's   disease   showing  the   thinned   skin    covering   it. 

suited  a  surgeon  who  removed  the  tumors.  In  nine  months  other 
tumors  develojped  and  the  same  surgeon  removed  them  also.  Within 
a  few  months  thev  returned  and  he  consulted  another  surgeon  who 


160  CLIXICAL   SURGERY    BY    CASE    HISTORIES 

cured  them  by  two  blood  transfusions.  That  is  now  nine  months  ago 
and  he  has  some  more  tumors  despite  the  cure.  His  general  health 
is  good. 

Examination. — On  the  left  side  of  the  neck  is  a  mass  the  size  of  an 
egg  situated  with  its  long  axis  directed  toward  the  mastoid  process. 
The  skin  over  it  is  thinned  and  of  a  reddish  color.  Anterior  to  this  is 
a  smaller  mass  over  which  the  skin  is  less  reddened.  Beneath  the 
chin  is  a  deeply  lying  one  over  which  the  skin  is  movable.  Above  the 
clavicle  a  number  of  other  nodules  are  palpable.  There  are  three  scars 
marking  the  site  of  previous  operations  (Fig.  75).  The  larger  nodule 
is  quite  firmly  fixed,  yet  possesses  a  certain  degree  of  mobility.  The 
right  side  of  the  neck  is  free  from  any  evidence  of  tumors.  General 
examination  fails  to  discover  anything  of  moment. 

Diagnosis. — Multiple  nodules  with  an  unchanged  blood  picture  in- 
dicates Hodgkin's  disease.  The  thinned  skin  over  the  larger  mass 
makes  it  likely  that  it  is  of  tlie  endothelial  type.  On  the  whole,  the 
case  presents  a  ratlier  uninviting  problem  for  surgical  interference, 
but  since  the  variety  is  endothelial  and  the  patient's  general  con- 
dition is  unimpaired,  it  seems  warranted  to  make  an  attempt  at  radi- 
cal removal. 

Treatment. — A  complete  block  dissection  of  the  neck  was  done,  leav- 
ing only  the  common  and  internal  carotid  vessels  and  the  large  veins. 

Pathology. — The  glands  removed  showed  an  endothelial  arrange- 
ment of  the  cells.  The  larger  gland  contained  a  cj'st  as  large  as  a  pig- 
eon's egg. 

After-course. — Six  months  later  glands  appeared  on  the  right  side 
of  the  neck  also.  A  complete  block  dissection  was  done  on  this  side 
of  the  neck.  He  remained  free  from  recurrence  for  a  year.  Then 
new  tumors  formed  back  of  the  mastoid  process  and  evidence  of  sub- 
sternal ccmpression  appeared.  He  lived  a  year  after  this.  The  right 
side  remained  free  from  recurrence. 

Comment. — The  endothelial  type  offers  some  promise  of  prolonged 
relief  by  early  radical  operation  but  even  these  are  bei?t  reached  by 
the  x-rays. 

CASE  4. — A  laborer  aged  forty  came  to  the  hospital  because  of 
tumors  of  his  neck. 

History. — For  several  years  the  patient  has  noticed  lumps  coming 
on  the  side  of  the  neck.     They  first  appeared  below  the  ear  but  soon 


DISEASES    OF    THE    NECK 


161 


they  extended  over  the  whole  right  side  of  the  neck.     The  left  side 
remained  free.     His  general  health  is  good. 

Examination. — A  nnmber  of  enlarged  glands  occupy  the  side  of 
the  neck.    They  varv  in  size  from  a  hickory  nnt  to  that  of  a  walnut. 


Fig.    76. — Cross   section   of  lymph  glands   in   a   case   of   endothelial   type   of   Hodgkin's   distase. 


■■m^?  ^ 


'•St* 


^i'. 


-f  ^'.^'^^  K^ 


;  y 


^ 


> 


Fig.    "". — Endothelial    lymph   glands    from    a    case    of   Hodgkin's   disease. 

They  glide  about  under  the  examining  finger  and  are  firm.  No  other 
glands  are  enlarged.    The  blood  picture  is  normal. 

Diagnosis. — The  large  size  of  the  glands  with  the  absence  of  soften- 
ing and  the  freedom  of  fixation  stamp  them  as  Hodgkin's  glands. 

Treatment. — The  neck  was  blocked  out. 


162  CLINICAL    SIRGKRY    BY    CASE    HISTORIES 

PatJtology. — The  larger  gland  .showed  areas  of  degeneration  which 
resemble  tuberculosis  superficially.  On  closer  inspection  the  areas 
are  seen  to  be  more  sharply  defined  and  of  a  more  yellow  color  (Fig. 
76).  The  slide  shows  the  picture  of  an  endotheliomatous  Hodgkin's 
disease  (Fig.  77). 

After-course. — The  patient  was  operated  on  by  a  junior  surgeon 
nnd  he  was  taken  from  the  operating  room  to  the  morgue. 

Comment. — These  specimens  resemble  carcinoma  closely.  The 
mother  cells  most  likely  arc  the  endothelial  cells  of  the  lymph  glands. 

CASE  5. — A  laborer  aged  forty  came  to  the  hospital  because  of 
a  tumor  in  his  neck. 

History. — For  two  years  he  has  had  tumors  in  the  neck.  He 
fir.st  noticed  them  at  the  upper  part  of  the  left  side.    They  caused  no 


Fig.  78. — Gross  appearance  ot  a  degenerated  Hodgkin's  gland. 

inconvenience  at  first  but  as  the  number  and  size  increased  the  move- 
ments of  his  head  were  interfered  with  and  he  began  to  feel  weak. 

Examination. — The  patient  presents  a  large  conglomerate  mass  on 
the  left  side  of  the  neck.  The  larger  one  of  the  masses  measures  6  x 
8  cm.     There  is  an  indefinite  number  of  smaller  ones.     The  masses 


DISEASES    OF    THE    NECK  163 

are  discrete  and  move  on  each  other  and  beneath  the  mnscles  which 
cover  them.    There  is  a  moderate  general  anemia. 

Diagnosis. — The  size  of  the  glands  and  the  little  tendency  to  invade 
the  capsule  stamp  them  as  Hodgkin's  disease.  Their  large  size  and 
rapid  development  together  with  the  age  of  the  patient  excludes 
tuberculosis. 

Treatment. — A  radical  blocking  of  the  neck  was  done. 

Pathology. — When  the  larger  of  the  glands  was  cut  through  it 
showed  a  uniform  Avhite  surface  for  the  most  part  with  only  small 
areas  where  the  original  gland  structure  was  retained.     The  degen- 


Microscopic  appearance   of  a  degenerated  Hodgkin's   gland   showing  preservation   of 
cells  about  a  vessel. 


cells  about  a  vessel 

crated  area  was  homogeneous,  not  granular  (Fig.  78).  About  the 
vessels  the  original  lymph  cells  were  presented.  The  microscopic  ap- 
pearance was  not  determinate  (Fig.  79).  The  smaller  glands  showed 
the  usual  picture  of  Hodgkin  's  disease,  being  marked  by  an  unusually 
large  number  of  eosinophiles. 

After-course. — The  glands  of  the  opposite  side  of  the  neck  began  to 
enlarge  soon  after,  followed  by  the  mediastinal  glands.  He  died  in 
Jess  than  a  year  under  the  typical  picture  of  malignant  lymphoma. 

Comment. — The  degenerations  of  lymphomas  resemble  tuberculosis 
in  general  outline.     Usually  the  degenerated  area  is  either  pearly, 


164 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


o'listening  in  color,  or  canary-yellow  in  color,  differino'  from  the  dirty 
white,  cheesy  color  of  tuberculosis. 

CASE  6. A  married  woman  aged  seventeen  came  to  the  hospital 

because  of  tumors  in  her  neck. 

History. — The  patient  is  the  mother  of  one  child.     Fifteen  months 


Fig.   SO. — Gross   appearance   of   pocket   of   tuberculous   lymph   glands   after    removal. 


DISEASES   OF    THE    NECK 


165 


ago  she  noticed  the  glands  of  the  left  side  of  the  neck  began  to  en- 
large. Those  near  the  angle  of  the  jaw  were  the  first  to  enlarge,  and 
were  followed  by  the  enlargement  of  those  of  the  entire  side  of  the 
neck.  There  were  no  other  enlarged  glands.  She  has  felt  a  general 
weakness  for  some  months. 

Exmnination. — The  entire  left  side  of  the  neck  is  occupied  by  a 
conglomerate  mass  of  glands.  They  are  easily  palpable  individually 
but  they  are  attached  more  or  less  closely  together.  There  are  no 
areas  of  softening.     Her  Hg.  is  70  and  the  white  count  5,000. 

Diagnosis. — The  characteristic  feature  is  the  attachment  of  the 
glands  to  their  environments.     The  enlargement  was  more  rapid  than 


Tuberculous    lymph   glands. 


is  usual  in  tuberculosis,  and  the  glands  more  discrete  than  is  usual 
in  this  disease.  In  Hodgkin's  disease  the  glands  usually  are  more 
freely  movable  on  each  other. 

Treatment. — The  entire  giandpack  was  removed  by  block  dissection 
(Fig.  80). 

Pathology. — A  number  of  the  glands  showed  central  caseation,  but 
nowhere  was  the  capsule  perforated.  The  caseated  area  was  sharply 
defined  as  in  Hodgkin's  disease  (Fig.  81).  The  slide  shows  tuber- 
culosis. 

After-course. — The  glands  on  the  opposite  side  of  the  neck  enlarged 
a  year  and  a  half  later  and  were  likewise  removed.  Four  years  later 
a  group  of  submental  glands  enlarged  and  were  likewise  removed. 
She  has  now  been  free  from  glandular  enlargement  for  several  years. 


166  CLINICAL    SURGERY    BY    CASE    HISTORIES 

Comment. — It  is  a  mistake  to  do  tliese  radical  operations  for  lymph 
gland  tuberculosis.  Had  I  to  manage  tins  patient  now  I  should  pro- 
ceed differently.  The  avenue  of  infection  is  generally  the  tonsils 
and  I  should  remove  these  and  allow  the  glands  to  take  care  of  them- 
selves. Radical  operation  is  objectionable  because  of  the  liability  of 
a  general  tuberculosis  taking  place  At  best  more  or  less  of  a  scar 
remains  permanently. 

CASE  7. — A  retired  physician  of  sixty-four  came  to  the  hospital 
because  of  a  series  of  tumors  on  the  side  of  the  neck. 

History. — For  six  or  eight  months  the  patient  has  noticed  an  en- 
iarg3ment  on  the  side  of  the  neck  below  the  angle  of  the  jaw.  This  was 
soon  followed  by  other  lumps  lower  down.  They  cause  no  considera- 
ble pain.  The  larger  tumors  were  aspirated  l)y  his  physician  and  a 
straw-colored  fluid  was  obtained. 

Examination. — The  tumor  nearest  the  jaw  is  the  size  of  a  hen's  eg^i. 
the  ones  lower  down  the  size  of  a  walnut  and  smaller.  The  upper  one 
is  soft  and  fluctuating,  but  not  painful.  The  lower  one  is  dense,  elastic. 
Both  are  fixed  to  the  surrounding  tissue  but  free  from  attachment  to 
the  skin.  There  is  an  ulcer  on  the  lower  surface  of  the  tongue  ex- 
tending to  the  floor  of  the  moutli.  It  lias  a  dense  edge,  the  outline 
is  irregular.  It  bleeds  when  manipulated.  Blood  counts  and  the 
various  laboratory  tests  had  been  made,   all   with  negative  results. 

Diagnosis. — The  ulcer  of  the  tongue  is  clearly  a  carcinoma,  though 
the  patient  seemed  to  be  ignorant  of  its  presence.  The  tumors  of  the 
neck  it  is  fair  to  assume  are  cancerous  also,  despite  the  fact  that  the 
larger  one  is  fluctuating  and  contains,  according  to  his  physician,  a 
straw-colored  fluid. 

Treatment. — At  the  urgent  solicitation  of  the  patient  a  block  dis- 
section of  the  neck  was  done.  The  operation  up  to  the  point  of  where 
the  growth  had  to  be  elevated  from  the  submental  space  was  done  un- 
der local  anesthesia.  A  general  anesthetic  was  used  in  the  final  steps  of 
the  operation.  Three  Aveeks  later  the  growth  in  the  mouth  was  re- 
moved under  local  anesthesia  with  an  electric  cautery.  An  attem])t 
was  made  to  give  a  general  auestlietic  for  the  second  operation,  but 
as  the  larj'nx  was  firmly  bound  down  as  a  result  of  the  very  radical 
dissection  done  three  weeks  before,  it  became  occluded  whenever  the 
patient  began  to  relax  fi'oiii  tlic  aiipsthetie. 


DISEASES    OF    THE    NECK 


167 


Pathology. — The  ulcer  in  the  mouth  was  a  typical  epithelioma.  The 
tumcrs  in  the  neck  were  cystic  (Fig.  82-B).  The  walls  of  the  cyst 
were  fairlv  smooth  and  seemed  to  he  lined  with  a  distinct  memhrane. 


Fig.  82. — Cys'ic  carcinoma  of  a  cervical  lymph  gland,  metastatic  from  a  carcinoma  of  the 
floor  of  the  mouth.  The  upper  figure  shows  the  spindleform  of  some  of  the  epithelial  cells. 
The  lower  figure  shows  the  cystic  gland  with  a  rim  of  cancerous  tissue  about  the  central 
cavity. 


The  solid  portions  of  the  tumor  showed  a  peculiar  admixture  of 
epithelial  cells  and  spindle-form  cells  as  though  an  epithelial  tumor 
was  intermingled  with  a  spindle-celled  sarcoma  fFig.  82- A) .    The  walls 


168  CLINICAL    SURGERY    BY    CASE    HISTORIES 

of  the  cyst  were  epitheliomatoiis.  The  cells  of  the  tumor  mass  in  some 
situations  were  spindleform  with  i)rononnced  reaction  of  the  connec- 
tive tissue,  remin(lin<i'  one  of  transition  tumors  sometimes  seen  in 
mice. 

After-course. — The  patient  recovered  well  from  the  operation.  Sev- 
eral months  later  he  began  to  have  violent  headaches.  These  increased 
in  intensity  and  he  died  in  delirium  after  a  partial  paralysis  of  the 
right  side,  i:)robal)ly  a  cerebral  metastasis. 

Comment. — It  is  curious  that  the  mouth  lesion  should  have  been 
overlooked  by  the  patient  who  was  himself  a  physician.  The  genesis 
of  the  cyst  was  due  probably  to  the  occlusion  of  a  lymph  sinus  and 
was,  therefore,  a  lymph  cyst  brought  about  by  the  metastatic  growth. 

CASE  8. — A  husky  farmer  aged  forty-six  came  to  the  hospital  be- 
cause of  a  tumor  under  his  jaw. 

History. — For  several  months  he  has  noticed  a  tumor  under  the 
edge  of  his  left  lower  jaw.  He  has  had  no  pain  but  a  certain  sense  of 
uneasiness.     He  has  had  no  throat  trouble  of  anv  sort. 


Fia.   S.i. — Gross   sc-ctioii   of   lymjin    gland. 

Examination. — Just  below  and  anterior  to  the  angle  of  the  jaw  is 
a  globular  mass  the  size  of  a  hulled  walnut.  It  is  smooth,  elastic, 
hard.  It  seems  to  be  free  from  its  environment.  AVhen  pressed 
upon  from  the  outside  it  protrudes  into  the  mouth  seemingly  being 
located  just  beneath  the  mucous  membrane  but  unattached  to  it. 
There  are  no  palpable  glands  and  there  is  no  lesion  in  the  mouth. 

Diagnosis. — Its  situation,  its  smooth,  ovoid,  and  apparently  tense 
elastic  character,  and  above  all  its  close  relation  to  the  buccal  mucous 
membrane,  made  me  regard  it  as  a  thyroglossal  cyst.  The  entire 
absence  of  palpable  glands  seemed  to  corroborate  this. 


DISEASES   OF    THE    NECK  169 

Treatment. — The  tumor  was  removed  under  local  anesthesia.  It  was 
found  to  be  a  solid,  well  encapsulated  tumor   (Fig.  83). 

Pathology. — For  some  reason  the  tumor  was  not  examined  at  onee. 

After-course. — The  wound  healed  promptly.  In  two  months  he 
returned  with  a  number  of  small  hard  glands  below  the  region  of  the 
operation.  These  were  evidently  malignant.  The  primary  tumor 
was  hurriedly  sought  and  examined.  It  proved  to  be  carcinomatous, 
and  squamous-celled  carcinoma  at  that  (Fig.  84).  Perfectly  formed 
pearls  were  found.     The  region  was  rayed  and  five  months  later  a 


Fig.    84. —  Microscopic   section    of   case    in    Fig.    83,    showing   pearl    formation. 


block  dissection  was  attempted.  This  was  followed  within  a  few 
months  by  a  return.  The  x-rays  were  again  used,  but  the  patient 
died  a  year  later. 

Comment. — The  source  of  the  squamous  cells  is  a  matter  of  pri- 
mary interest.  No  lesion  could  be  found  in  the  mouth  or  any  other 
tributary  region.  The  next  most  obvious  source  of  squamous  cells 
would  be  a  tumor  developing  in  a  gill  cleft  rest.  There  was  a  border 
of  lymphatic  tissue  in  the  primary  tumor.  Since  lymphoid  tissue  is 
often  found  about  gill  clefts,  this  point  does  not  aid  in  deciding  as 
to  whether  the  tumor  was  primary  in  this  region  or  was  transported 
to  a  lymph  gland  from  a  distance.  It  is  of  importance  to  note  that  the 
carcinomatous  nature  of  a  tumor  of  the  neck  is  not  ruled  out  because 


17U 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


a  primary  tumor  is  not  found.  I  have  in  a  number  of  instances  made 
that  error.  If  a  pre-operative  diagnosis  is  not  made  the  section  of  the 
tumor  should  not  be  neglected.  So  far  as  the  patient's  welfare  is 
concerned,  it  makes  no  difference.  I  have  never  yet  cured  a  patient 
who  had  any  malignant  disease,  primary  or  secondary,  in  the  neck. 
But  it  is  a  source  of  personal  comfort  to  accurately  call  the  coming 
course  of  events. 

CASE  9. — A  housewife  of  thirty-four  years  of  age  came  because 
of  a  swelling  under  the  left  jaw. 


Fig.   83. — Lymphosarcoma   of   the   submaxillary   lymph   gland. 

History. — The  patient  has  always  enjoyed  good  health.  Three 
mouths  ago  she  noticed  an  enlargement  below  the  lower  jaw  on  the 
left  side.  It  is  slightly  painful  but  the  chief  complaint  is  the  dis- 
Mgurement. 


DISEASES    OF    THE    NECK 


171 


Examination. — A  mass  the  size  of  a  bantam  egg  is  located  over  the 
lower  border  of  the  jaw  just  in  front  of  the  angle  (Fig.  85).  It  is 
folded  over  the  edge  of  the  jaw  like  a  ball  of  mnd  over  the  edge  of  a 
board.  It  is  elastic,  firm  and  uniform.  It  is  attached  to  the  bone 
but  the  skin  and  superficial  fascia  move  freely  over  it. 

Diagnosis. — The  tumors  in  this  region  when  single  are  usually  in- 
fected lymph  glands  but  an  acute  infection  should  have  suppurated  or 
regressed  by  this  time.  There  was  no  apparent  lesion  in  the  mouth. 
Tuberculous  glands  are  situated  further  down  the  back  and  usually 
multiple  and  are  not  so  intimately  attached  to  the  bone.     Solitary 


Fig.   86. — Lymphosarcoma   of  a  submaxillary  lymph   gland. 

tumors  in  this  region  are  usually  lymphosarcomas  but  this  one  seems 
to  have  come  up  too  suddenly  and  then  remained  stationary  too  long 
to  warrant  this  diagnosis.  Excision  was  decided  on  to  clear  up  the 
matter. 

Treatment. — The  tumor  was  removed  and  the  submental  triangle 
was  dissected  out. 

Pathology. — The  tumor  on  gross  appearance  is  uniformly  pinkish, 
the  surface  moist  and  glistening  with  no  areas  of  degeneration.  The 
sections  showed  a  typical  lymphosarcoma   (Fig.  86). 

After-course. — There  was  a  recurrence  within  three  months. 

Comment. — The  operation  done  was  wholly  inadequate.  The  whole 
side  of  the  neck  sliould  liave  been  blocked  out  or  better  still,  no  op- 


172 


CLINICAL    SL'RGERY    BY    CASE    HISTORIES 


eration  at  all  attempted.     The  x-ray  has  but  little  effect  on  this  type 
of  tumor,  but  does  more  than  operation  to  stay  their  course. 

NONLYMPHATIC  TUMORS  OF  THE  NECK 


Tumors  of  the  neck  not  associated  with  the  lymph  glands  are  usu- 
ally solitary  and  of  slow  growtli.  They  are  usually  a  part  of  or  are 
associated  M'ith  some  of  the  parenchymatous  organs  and  are  nearly 
alw^ays  unilateral. 

CASE  1. — A  married  woman  aged  fifty-four  came  because  of  nerv- 
ousness and  loss  of  weight. 


Fig.   87. — Aberrant  thyroid  at  the  angle   of  the  jaw. 

History. — She  formerly  had  good  health,  but  for  the  past  several 
months  she  has  been  very  nervous  and  has  lost  more  than  thirty 
pounds  in  weight.  She  becomes  easily  fatigued  and  perspires  easily 
on  effort  or  exertion.    The  appetite  is  fair.     Sleep  is  variable. 


DISEASES    OF    THE    NECK  173 

Examination. — The  patient's  eyes  are  markedly  protruding.  Stel- 
wag's,  Kocher's  and  Dalrymple's  signs  are  all  positive.  She  has  a 
marked  tremor  of  the  hands.  The  pulse  is  132,  full  and  bounding. 
The  thyroid  is  not  palpable.  On  the  left  side  of  the  neck  below  the 
angle  of  the  jaw,  is  a  tumor  the  size  of  a  walnut.  It  is  pulsatile,  al- 
most expansile.  When  jDressed  upon,  it  protrudes  into  the  floor  of 
the  mouth  at  the  base  of  the  tongue.  The  apex  beat  of  the  heart 
is  diffuse  and  near  the  axillary  line. 

Diagnosis. — The  patient  unquestionably  has  an  "exophthalmic  goi- 
ter. ' '  The  goiter,  however,  is  not  in  evidence.  The  thyroid  is  not  defi- 
nitely palpable.  The  tumor  at  the  angle  of  the  jaw,  however,  has  the 
expansile  feeling  of  a  toxic  goiter.  The  pulsation  of  the  vessels  is 
identical.  The  close  association  with  the  floor  of  the  mouth  at  the 
base  of  the  tongue  seems  to  line  it  \\p  with  the  accessory  thyroids 
located  at  the  base  of  the  tongue.  The  patient  is  too  toxic  to  permit 
of  operation.  It  would  be  a  typical  case  for  pole  ligation  if  one 
knew  where  the  pole  is  located. 

Treatment. — Rest  in  bed  and  bromides. 

After-course. — In  the  three  months  following  she  regained  her 
weight  and  the  pulse  was  reduced  to  90.  The  tumor  reduced  some- 
what in  size  and  the  pulsations  ceased.  She  has  now  been  in  good 
general  health  for  three  years  past.  The  tumor  is  reduced  to  the 
size  shown  in  Fig.  87.  There  is  still  marked  exophthalmos,  and  she 
is  easily  fatigued  and  excited.     The  tumor  does  not  pulsate. 

Comment. — Unfortunately  histologic  verification  of  the  diagnosis 
can  not  be  offered.  After  the  patient  reached  a  state  where  operation 
would  have  been  safe,  she  was  improving  so  rapidly  that  she  refused 
operation. 

CASE  2. — A  farmer  aged  fifty-tv70  came  to  the  hospital  because 
of  pain  all  over  the  left  side  of  the  face  and  a  mass  under  the  lower 
jaw. 

History. — Twentj'-five  years  ago  he  had  an  attack  of  acute  fever 
of  some  kind.  He  was  in  a  hospital  in  New  Mexico  for  six  weeks. 
He  does  not  know  what  it  was,  but  he  made  a  complete  recovery. 
Twenty  years  ago  he  had  an  attack  of  severe  pain  running  down  the 
back  of  the  left  thigh  and  leg.  He  says  that  all  of  his  extremities 
were  attacked  later  by  the  trouble,  lasting  a  year.  His  hands  and 
feet  and  face  became  puffy,  but  not  all  at  the  same  time.    The  pain 


174 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


Avas  severe  and  shooting.    He  says  the  joints  enlarged.    A  diagnosis 
of  inflammatory  rheumatism  was  made. 

Seventeen  years  ago,  while  he  was  riding  a  wheat  binder,  he  had 
a  sudden  severe  pain  in  the  left  ear.  He  thought  a  bug  had  entered 
his  ear.  The  pain  spread  from  the  ear  out  over  the  face  but  never 
crossed  the  median  line  of  the  face.  Some  pain  is  present  all  the 
time,  but  it  gets  worse  every  night  and  keeps  him  awake.  The 
pain  extends  clear  up  the  side  from  the  lower  edge  of  the  jaw  to 
midline  of  the  sealp.     Rubbing  the  side  of  the  face  and  scalp  gives 


Fig.  88. — Mixed  tumor  of  the  submaxillary  gland. 

relief.  Cold  draughts  of  air  start  the  pains  and  make  them  worse. 
The  pain  seems  to  radiate  from  the  ear. 

Three  years  after  the  attack  of  pain  he  noticed  a  hard  kernel  in 
the  region  of  the  submaxillary  gland.  This  has  grown  steadily, 
but  has  grown  worse  more  rapidly  during  the  past  year.  During  the 
past  month  his  pain  has  been  much  worse  and  constant. 

He  passes  a  great  deal  of  urine.  Gets  up  four  to  six  times  at 
night.  Is  rather  constipated  most  of  the  time.  Xo  pain  or  difficulty 
on  urination.  Has  had  some  trouble  with  his  eyes,  can  not  read 
without  glasses.    Xever  has  a  headache. 


DISEASES    OF    THE    NECK 


175 


Examination. — Pupils  react  to  light  and  accommodation.  AVell  de- 
veloped arcus  senilis  for  a  man  of  his  age.  Throat  negative.  Tumor 
the  size  of  a  hen's  egg  on  the  left  side  under  the  mandible  in  the  re- 


Fig.   89. — Gross  section  of  mixed  tumor  of  the  submaxillary  gland- 


Fig.   90. — Mixed  tumor  of  the  submaxillary   gland. 


gion  of  the  submaxillary  gland  (Fig.  88).  It  is  very  hard,  freely 
movable,  and  somewhat  nodular. 

Diagnosis. — The  long  duration  of  the  growth,  its  hardness  and  ir- 
regular surface  is  diagnostic  of  a  mixed  tumor. 

Treatment. — The  tumor  was  removed  under  local  anesthesia.  It  was 
freely  movable  and  unattached. 


176  CLINICAL    SURGERY    BY    CASE    HISTORIES 

PatlioIoiJ!/. — Tli(»  section  showed  a  glistening  snrface  and  fine  points 
visible  in  some  areas  (Fig.  89).  The  slide  showed  the  usual  ad- 
mixture of  endothelioma  and  myxoid  tissue  (Fig.  90).  It  is  evi- 
dently a  mixed  tumor  of  the   submaxillary  gland. 

After-course. — He  has  remained  free  from  recurrence  three  years. 

Commoif. — The  patient  sought  to  connect  the  tumor  with  the  past 
ailments,  but  there  is  no  evidence  that  such  was  the  case.  The  mixed 
tumors  run  their  course  wholly  without  symptoms. 

CASE  3. — A  school  teacher  aged  forty  came  to  the  hospital  be- 
cause of  a  tumor  of  the  neck. 

Ilistorij. — When  thirteen  years  old,  this  patient  first  noticed  a  small 
lump  under  the  lobe  of  her  left  ear.  It  grew  slowly,  reaching  the 
size  of  a  walnut  one  year  ago.  At  this  time  it  became  painful  and 
began  to  grow  rapidly.  It  seems  to  vary  in  size  and  when  large  is 
quite  painful. 

Examination. — In  front  and  below  the  left  ear  is  a  tumor  the  size 
of  a  small  orange  (Fig.  91).  It  is  bosselated,  varying  in  density  in 
the  different  regions  and  is  fixed  to  the  underlying  tissue.  From  this 
growth  downward  along  the  anterior  border  of  the  sternomastoid  is 
a  series  of  nodules  varying  in  size  from  a  pea  to  a  large  hazelnut. 
There  is  a  larger  group  behind  the  mastoid  extending  downward. 
These  nodules  are  somewhat  movable  laterally  on  the  underlying  tis- 
sue but  do  not  move  vertically. 

Diagnosis. — The  location,  the  long  period  of  development,  the  bosse- 
lated surface  and  the  varying  consistency  stamp  the  growth  as  a  mixed 
tumor  of  the  parotid.  There  is  no  other  type  in  this  region  that 
develops  so  slowly.  The  secandary  growths  are  evidently'  metastases. 
While  mixed  tumors  of  the  parotid  are  little  disposed  to  form  metas- 
tases, thej'  may  do  so.  When  they  take  on  rapid  growth  as  the  his- 
tory indicates  this  one  has  done,  they  commonly  metastasize  by  way 
of  the  lymphatics.  The  small  tumors  in  the  neck  are  evidently  of 
this  character.  In  epithelial  metastatic  tumors  cure  is  hopeless,  but 
in  the  case  of  mixed  tumors,  cure  may  be  hoped  for  even  after  the 
lymph  glands  have  become  involved. 

Treatment. — The  entire  side  of  the  neck  was  l)locked  out  includ- 
ing the  vein  and  external  carotid  artery.  The  entire  parotid  was 
removed,  the  facial  nerve  being  disregarded  in  the  operation. 


DISEASES    OF    THE    XECK 


177 


Pafhology. — The  growtli  is  typical  of  a  mixed  tumor.  There  is 
an  admixture  of  myxoid  areas  and  a  few  islands  of  cartilage  along 
with  the  usual  endothelial  cells.  The  endothelial  areas  particularly 
show  activity.  The  gland  metastases  show  only  the  deA'elopment  of 
the  endothelial  cells. 

After-course. — The  patient  developed  an  erysipelas  in  the  wound 
on  the  fourth  day  and  was  very  sick  for  a  week.  As  often  occurs  in 
erysipelas  in  a  wound,  once  the  infection  subsides,  wound  healing  is 
astonishingly  rapid,  so  in  this  case  at  the  end  of  two  weeks  the  wound 


Fig.   91. — Mixed  tumor  of   the   parotid. 

was  entirely  healed.  The  patient  remained  well  for  six  months. 
While  sitting  in  the  basement  in  June  she  became  somewhat  chilled. 
As  she  sought  to  arise  to  go  upstairs  she  experienced  an  acute  lumbar 
pain.  The  diagnosis  of  lumbago  was  made  on  telephonic  description 
of  symptoms.  There  was  no  improvement  and  at  the  end  of  a  month 
numbness  of  one  leg  was  complained  of.  The  patient  was  visited 
at  this  time  and  a  metastatic  tumor  of  the  cord  diagnosed.  At  opera- 
tion a  tumor  1.5  x  1  x  0.5  cm.  was  found  extradurally.  This  was 
easily  removed.  The  patient  unfortunately  died  on  the  tenth  day 
after  operation  from  postoperative  pneumonia. 


178 


CLINICAL    SURGERY    BY    CASE   HISTORIES 


Comment. — "While  mixed  tumors  present  a  prospect  of  a  cure  after 
they  have  reached  a  degree  of  development  which  would  render  other 
tumors  utterly  hopeless,  it  is  more  than  doubtful  whether  one  is  war- 
ranted in  going  to  the  extent  of  removing  a  metastatic  nodule  from 
the  ccrd. 

CASE  4. — A  farmer  a^'ed  forty-eight  came  for  relief  from  a  recur- 
rent tumor  of  his  neck. 

History. — A  dozen  years  ago  he  noticed  a  tumor  in  front  of  and 
below  the  ear.     This  grew  in  size  until  it  became  nearlv  as  large  as  a 


Fig.    92. — Recurrent   mixed    tumor    of    tlie    parotid. 


hen's  Qgg.  This  was  removed  two  years  ago  by  a  capable  surgeon. 
A  nodule  just  below  the  site  of  the  first  operation  was  removed  a  year 
ago.  Others  scon  formed  and  one  of  these  has  ulcerated.  He  has  a 
persistent  cough  and  raises  some  mucus.  He  has  had  a  similar  cougli 
in  previous  winters.     Otherwise  his  health  is  good. 

Examination. — There  is  a  scar  parallel  with  the  loAver  border  of  the 
jaw  extending  frcm  the  tip  of  the  mastoid  process  nearly  to  the  tip  of 
the  chin.  Below  this  is  a  conglomeration  of  nodules  about  the  size 
of  hazelnuts.     Thev  extend  down  as  far  as  the  lower  border  of  the 


DISEASES    OF    THE    NECK 


179 


hyoid  tone.  They  are  quite  firmly  fixed  to  their  euvironment.  There 
is  a  nodule  in  the  skin  below  the  tip  of  the  ear  and  below  this  is  a 
superficial  ulcer  the  size  of  a  dime.  Repeated  examination  of  the 
respiratory  organs  fails  to  discover  any  lesion  save  a  chronic  pharyn- 
gitis.    (Fig.  92.) 

Diagnosis. — From  the  history'  it  seems  most  likely  that  the  primary 
tumor  was  a  mixed  tumor  of  the  submaxillary  gland  and  that  the 
nodules  now  present  are  metastatic.  Because  of  this  fact  their  re- 
moval seems  worth  attempting.  The  presence  of  a  cough  in  a  patient 
with  a  recurrent  tumor  is  a  matter  to  cause  grave  apprehension.    The 


Fig.  93. — Slide  of  recurrent  mixed  tumor  of  the  submaxillary  gland. 


assumption  is  that  there  is  a  lung  metastasis.  The  fact  that  the  lung 
findings  are  negative  is  by  no  means  a  valid  argument  that  none  exists. 
The  fact  that  he  has  had  cough  during  the  winter  for  a  number  of 
years  gives  warrant  to  the  hope  that  he  now  has  only  a  recurrence  of 
this  and  that  a  laryngitis  and  tracheitis  is  the  extent  of  his  disability. 
The  fact  that  mixed  tumors  are  little  likely  to  metastasize  here  like- 
wise enters  the  argument. 

Treatment, — The  entire  side  of  the  neck  was  blocked  out  under 
quinine  and  urea-hydrochloride  anesthesia.  The  internal  jugular  vein, 
the  external  carotid  artery,  and  the  vagus  and  hypoglossal  nerves 
were  removed.    Because  of  the  close  association  of  the  growth  to  the 


180 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


skill  a  considerable  area  of  it  had  to  be  removed.  This  was  replaced 
by  sliding  a  flap  from  the  lower  part  of  the  back  of  the  neck. 

Pathology. — The  glands  showed  the  nsnal  picture  of  metastasis  in 
mixed  tumors  of  the  parotid.  The  typical  endothelial  arrangement  of 
the  cells  is  maintained  even  in  the  recurrences  in  the  skin  (Fig. 
93). 

After-course. — He  has  been  free  more  than  ten  years  after  the 
operation. 

Comment. — Experience  alone  can  prove  whether  such  extensive 
operations  are  warranted  in  metastasis  after  mixed  tumors  of  the 
parotid.  Any  recurrence  following  mixed  tumors  of  any  of  the  sali- 
vary' glands  that  is  technically  operable  offers  some  hope  of  a  cure. 
In  following  this  principle  I  have  not  hesitated  to  remove  all  the 
large  nerves  and  vessels  from  the  side  of  the  neck.  AVhen  one  con- 
siders that  anything  less  will  most  certainly  end  fatally,  almost  any- 
thing that  offers  any  prospect  of  result  is  justified.  This  is  partic- 
ularly true  if  the  patient  has  the  intelligence  to  comprehend  the 
situation  and  is  allowed  to  elect  his  fate. 

CASE  5. — A  merchant  aged  sixty  came  because  of  an  ulcer  below 
his  left  ear. 


*V 


/ 


Fig.  94. — Carcinoma  of  the  neck. 


History. — For  a  year  and  a  half  he  has  had  an  ulcer  on  the  side  of 
the  neck.  It  is  scabbed  over  much  of  the  time  but  more  recently  the 
discharge  has  elevated  the  crust  and  escaped  down  his  neck.  For  this 
reason  he  wants  it  removed. 


DISEASES    OF    THE    XECK  181 

Examination. — An  nicer  the  size  of  a  half  dollar  is  located  just 
below  and  posterior  to  the  angle  of  the  jaw.  The  edges  are  distinctly 
elevated  and  hard.  The  nicer  itself  when  cleaned  of  scab  presents  an 
irregular  granular  base.  The  edge  of  the  ulcer  presents  fine  pin- 
point white  clots  when  pressed  upon  with  a  glass  slide.  The  ulcer 
does  not  move  freely  over  the  platysma,  but  ulcer  with  platysma 
can  be  freely  moved  over  the  deeper  structures  of  the  neck  (Fig.  9-1). 

Diagnosis. — The  location,  the  hard  border  and  the  close  association 
with  the  platysma  is  suggestive,  and  the  small  points  are  diagnostic  of 
carcinoma.  The  deep  association  with  the  platysma  characterize  it 
as  the  deep  form  as  distinguished  from  the  basal-celled  type. 

Treatment. — The  ulcer  with  a  half-inch  margin  together  with  the 
platysma  and  fascia  were  removed. 

Patliology. — The  lesion  is  a  typical  squamous-celled  cancer  with 
pearl  formation. 

After-course. — There  has  been  no  recurrence,  many  years  after. 

Comment. — This  type  is  best  treated  by  operation.  All  pearl- 
forming  epitheliomas  are  destroyed  with  difficulty,  although  very  ex- 
pert 5-ray  men  accomplish  the  task. 

CYSTIC  DISEASES  OF  THE  NECK 

Cystic  diseases  of  the  neck  are  usually  associated  with  some  dis- 
turbance in  development.  For  this  reason  their  location  is  always 
a  prominent  factor  in  diagnosis.  When  not  so  situated  a  cystic  tu- 
mor is  usually  due  to  secondary  changes  in  a  previously  solid  tumor. 

CASE  1. — A  farm  laborer  aged  thirty  came  to  the  hospital  because 
of  a  tumor  on  the  side  of  the  neck. 

History. — He  has  noticed  a  tumor  on  the  side  of  his  neck  for  a 
period  of  years.  It  has  gradually  developed  to  its  present  size.  It 
has  never  caused  pain  or  inconvenience. 

Examination. — In  front  of  and  overlying  the  sternomastoid  muscle, 
extending  from  the  mastoid  to  the  level  of  the  hyoid  bone  (Fig.  95) 
is  a  smooth  elastic  tumor.  It  does  not  move  with  deglutition.  When 
pressed  upon  it  can  be  made  to  bulge  into  the  floor  of  the  mouth. 

Diagnosis. — Its  close  relation  to  the  floor  of  the  mouth,  the  super- 
ficial position  of  its  outer  j^ortion,  and  its  smooth  elastic  feel  charac- 
terize it  as  a  thyrogiossal  cvst.     There  is  nothing  that  could  be  con- 


182 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


fused  with  it.    Lymph  cysts  are  vastly  softer  and  do  not  approach  so 
close  to  the  floor  of  the  mouth. 


Fig.   95.— Gill  cleft  cyst. 


-B 


Fig.    96._Gill    cleft    cyst.       A.  Area    covered    with    flat    epithelium.      B.  Area    of    columnar 
epithelium  forming  papillary   projections. 

Treatment. — It  was  excised  under  local  anesthesia. 
Pafholofii/.—The  cyst  wall  was  fairly  firm,  the  contents  clear.     TIk- 


DISEASES    OF    THE    XECK 


18.: 


lining  for  the  most  part  was  smootli  witli  a  small  area  covered  with. 
papillary  projections  (Fig.  96). 

After-course. — Healing  was  without  note. 

Comment. — These  tumors  must  be  approached  through  a  liberal 
incision  so  that  the  deeper  parts  can  be  fully  exposed.  They  are  oc- 
casionally the  site  of  carcinomas. 

CASE  2. — A  farmer  lad  of  eig^hteen  came  because  of  a  swelling- 
under  his  jaw. 

History. — For  nine  months  he  has  noticed  a  bulging  under  his  right 
jaw.  It  causes  him  no  pain  but  a  sense  of  fullness  under  his  tongue. 
This  is  augmented  when  he  presses  on  it. 

Examination. — A  mass  the  size  of  an  egg  is  visible  under  the  bor- 
der of  his  inferior  maxilla  fFig.  97).    It  is  smooth,  soft  and  fluctuat- 


Fig.  97. — Ranula  bulging  beneath  the  angle  of  the  jaw. 


184  CLINICAL   SURGERY    BY    CASE    HISTORIES 

ing.  "When  pressed  upon,  it  seems  to  disappear  iii  tlie  deptli  of  tlie 
floor  of  the  mouth.  When  the  mouth  is  inspected  while  pressure  is 
being  made,  a  blue  ridge  is  seen  to  appear  in  the  floor  of  the  mouth 
extending  as  far  forward  as  the  frenulum. 

Diag)iosis. — The  appearance  under  the  tongue  is  that  of  a  ranula. 
The  larger  cyst  under  the  jaw  appears  to  be  a  continuation  of  it.  The 
cyst  in  the  neck  must  therefore  be  a  bulging  rauula. 

Treatment. — The  top  of  the  protruding  mass  under  the  tongue  was 
cut  off  and  the  stringy  contents  mopped  out.  The  entire  sac  was 
then  swabbed  out  with  iodine  and  packed  with  gauze. 

After-course. — The  gauze  was  remoYcd  on  the  fifth  day.  Com- 
plete obliteration  of  the  sac  took  place. 

Comment. — There  may  be  a  question  whether  this  had  not  better 
be  called  a  cyst  of  the  sublingual  gland.  It  is  worth  noting  that  it 
was  cured  without  an  external  incision.  If  these  cysts  are  attacked 
by  open  incision  and  the  sac  is  not  fully  removed,  a  false  cyst  may  be 
formed  in  the  neck  which  may  become  large  and  involve  the  deep 
structures  recpiiring  a  difficult  dissection  for  its  eradication. 

CASE  3. — A  matron  aged  fifty-four  came  to  the  hospital  because 
of  a  tumor  in  her  neck  below  the  angle  of  the  jaw. 

History. — For  seme  mouths  she  has  noticed  a  lump  in  her  neck 
below  her  jaw.  It  caused  no  inconvenience  and  she  disregarded  it. 
Recently  it  has  enlarged  more  rapidly  and  is  painful.  Her  general 
health  has  been  good. 

Examination. — Her  general  appearance  confirms  her  judgment  as 
to  the  state  of  her  general  health.  In  front  of  the  sternomastoid  just 
below  the  level  of  the  hyoid  bone  is  a  tumor  the  size  of  a  hickory  nut. 
The  skin  over  it  is  reddened  and  somewhat  attached  to  it.  It  seems 
imbedded  in  the  superficial  structures  of  the  neck.  It  can  be  dis- 
placed in  various  directions,  along  with  the  superficial  structures,  save 
downwards.  "Wlien  pulled  downwards  it  seems  restrained  by  a  deep 
attachment.     There  are  no  lymph  glands  palpable. 

Diagnosis. — A  tumor  which  is  globular,  and  attached  to  the  skin, 
is  usually  a  wen.  and  when  inflammation  or  thickening  exists  these 
are  usually  ascribed  to  secondary  changes.  In  the  neck,  however,  wens 
are  rare  and  since  this  is  in  the  line  where  thyroglossal  ducts  are 
prone  to  lie  and  particularly  since  this  has  a  stalk  that  seems  to  keep 
it  from  being  depressed  downwards,  the  best  diagnosis  seems  to  be 


DISEASES    OF    THE    NECK  185 

a  thyrogiossal  remnant  which  has  become  inflamed.  While  this  tumor 
is  attached  to  the  skin,  it  does  not  seem  directly  attached  to  it  as 
one  would  expect  in  the  case  of  a  wen.  Furthermore  it  does  not 
protrude  from  the  surface  as  wens  do.  The  same  topography  applies 
to  dermoids.  They  are  prone  to  extend  beyond  the  surface.  Be- 
sides this  is  away  from  the  line  of  location  of  dermoids.  Why  it 
should  be  so  dense  is  another  question.  It  is  reddened  and  painful 
and  this  seems  the  best  reason  for  its  density,  though  for  it  to  be  so 
hard,  the  history  should  indicate  its  presence  for  a  longer  time. 

Treatment. — The  tumor  was  widely  excised.  When  it  was  exposed 
a  stalk  was  found  which  reached  to  the  floor  of  the  pharynx.  The 
deep  opening  was  closed  by  a  series  of  layers  of  catgut. 

Pathology. — The  tumor  is  firm,  whitish  and  on  section  a  thick 
white  wall  with  a  central  cavity  the  size  of  a  hazelnut  is  found.  The 
white  wall  contains  many  fine  punctiform  dots  obviously  carcinoma. 
The  slide  shows  it  to  be  a  sciuamous-celled  carcinoma. 

After-course. — The  patient  has  remained  free  from  recurrence  now 
four  years. 

Comment. — According  to  the  literature,  these  tumors  always  return. 
This  seems  to  have  been  removed  early  and  wide.  The  secondary  in- 
fection served  to  compel  the  patient  to  seek  surgical  relief  which 
she  most  likely  would  not  have  done  had  this  complication  not  super- 
vened. 

CASE  4. — A  college  girl  aged  twenty-two  came  to  the  hospital 
because  of  a  swelling  on  her  neck. 

History. — Five  years  ago  the  patient  noticed  a  swelling  in  the  mid- 
line of  the  neck.  It  was  not  painful  but  disturbed  her  esthetic  sense. 
She  was  operated  on,  but  after  a  few  months  a  sinus  formed.  This 
was  operated  on  and  again  after  a  few  months  a  fistula  reformed. 
This  same  procedure  was  repeated  twice,  and  at  the  present  time,  there 
is  still  some  discharge  in  a  dimple  in  the  old  scar. 

Examination. — The  patient  has  a  scar  in  the  midline  of  the  neck 
a  centimeter  wide  by  seven  centimeters  long.  At  the  junction  of  the 
upper  and  middle  third  is  a  discharging  sinus.  A  fine  wire  probe 
passes  up  the  sinus  to  near  the  base  of  the  tongue. 

Diagnosis. — The  position  in  the  midline  and  the  extent  of  the  tract 
stamps  it  as  a  thyrogiossal  duct.     The  persistence  in  the  midline  dif- 


186 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


ferentiates  it  from  a  gill  cleft  sinus  which  would  deviate  to  one  or 
the  other  side  as  it  approached  the  floor  of  the  mouth. 

Treatment. — The  old  scar  was  excised  and  followed  up  beyond 
the  site  of  the  previous  ojieration  where  ihe  unchanged  duct  was 
found.  It  seemed  to  pass  through  the  body  of  the  hyoid  bone,  con- 
sequently a  part  of  this  was  resected.  By  separating  the  hyoglossus 
muscles  and  the  geniohyoglossus,  the  tract  was  followed  to  the  base 
of  the  tongue  (Fig.  98).  The  duct  was  carefully  isolated  at  the 
lower    surface    of    the    mucous    membrane    of    tlie    tongue    and    cut 


iMg.   98. — Schematic   representation   of   tlie   thyroglossal   duct. 

off  without  opening  into  the  mouth.  The  soft  parts  were  coapted  with 
fine  catgut  and  the  wound  closed  without  drainage. 

Pathology. — The  duct  was  lined  with  cuboidal  and  columnar  epi- 
thelium. 

After-course. — There  has  been  no  recurrence  after  seven  years. 

Comment. — The  point  of  interest  lies  in  the  evidence  of  the  futility 
of  operating  on  these  cases  unless  the  entire  tract  is  cleanly  removed. 
This  is  not  easy,  and  unless  care  is  exercised,  they  are  apt  to  be  lost  in 
the  region  of  the  hyoid  bone.  They  sometimes  pass  in  front,  some- 
times behind  and  sometimes  through  the  bodv  of  this  bone. 


DISEASES    OF    THE    NECK 


187 


CASE  5. — A  retired  farmer  aged  sixty-four  came  because  of  a 
tumor  on  his  neck. 

History. — For  twenty  years  he  has  had  a  gradually  growing  tumor 
of  the  neck.  He  was  a  widower  and  the  reason  why  without  addi- 
tional provocation  he  desired  his  old  friend  removed  was  not  dis- 
cussed. 

Examination. — A  fiat  globular  tumor  occupies  the  right  half  of 
the  neck  immediately  below  the  external  occipital  protuberance.     It 


Fig.  99.— Wen  of   the   neck. 

is  smooth,  semifluctuating,  somewhat  attached  to  the  skin,  but  free 
for  the  most  i3art,  and  entirely  painless.     (Fig.  99.) 

Diagnosis. — Its  semielasticity,  its  very  slow  growth,  and  the  ten- 
dency to  lobulation  downward  seem  to  stamjD  it  as  a  lipoma.  The  skin 
seems  suspiciously  adherent  to  its  surface,  however,  but  the  thick 
skin  of  the  neck  makes  it  difficult  to  determine  definitely  whether 
or  not  the  tumor  is  attached. 

Treatment. — An  elliptical  incision  enclosing  an  area  of  skin  1x2 
inches  was  made.     When  the  mass  was  exposed  it  was  found  to  be 


188 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


a  wen  instead  of  a  lipoma.  Care  was  exercised  and  tlie  cyst  removed 
intact. 

After-cotirsc. — Pi'imary    healing. 

Comment. — Wens  usnally  project  out  as  globular  masses  but  when 
very  slowly  growing,  may  make  themselves  comfortable  habitants  in 
the  body  of  the  underlying  muscles.  Errors  in  diagnosis  have  no 
greater  significance  than  disturbing  the  harmonious  appearance  of 
the  operation  record  card. 

CASE  6. — A  matron  of  fifty-two  came  to  the  hospital  because  of  a 
tumor  on  her  neck. 

Hisfory. — She  lias  noticed  a  tumor  on  her  neck  for  a  number  of 


Pig    100.— Dci  moid  cyst   of  Uie   midline   of  the   neck. 

years.  It  has  gradually  enlarged,  but  causes  no  pain.  She  desires  to 
be  rid  of  it  because  of  its  appearance.     Iler  general  health  is  good. 

ExaminaUon.—JuBt  above  the  level  of  the  hyoid  bone  is  a  tumor  the 
size  of  a  hulled  walnut  (Fig.  100).  It  is  unattached  to  the  skin,  is 
smooth,  elastic,  and  painless.  It  is  slightly  movable  laterally,  but  not 
vertically.    It  moves  with  the  larynx  in  deglutition. 

Diagnosis.— The  movement  with  deglutition  establishes  it  as  being 
connected  with  the  deeper  structures.  Being  free  from  the  skin  it  is 
not  a  wen  and  is  not  likely  to  be  a  bronchiagenetic  rest. 

Treat  mod. — The  tumor  contains  a  gummous  material.  The  cyst 
wall  was  attached  by  a  stalk  Avith  the  hyoid  bone. 


DISEASES    OP   THE    NECK  189 

Pathology. — The  sac  was  smooth-walled  which  the  slide  showed  to 
be  lined  with  squamous  epithelium  (Fig.  101). 
After-course. — Healing  was  uneventful. 
Comraent. — These  deeply  Ijnng  cysts  must  be  removed  with  care 


*.;.al«««^*««ri.      i-"^  "  -■-•■    '-V  'j  '^■1*?V' 


Fig.    101. — Dermoid    cyst    of   the   midline   of   the    lu-ck. 

lest  a  stalk  extending  toward  the  base  of  the  tongue  be  overlooked 
and  a  sinus  result. 

INFLAMMATORY  DISEASES  OF  THE  NECK 

Inflammatory  affections  of  the  neck  are  usually  self-evident.  When 
there  is  any  reasonable  doubt  the  probability  is  that  the  disease  is 
neoplastic  and  not  inflammatory.  Inflammatory  affections  of  long 
duration,  notably  the  woody  phlegmons,  are  diffuse  and  therefore 
do  not  present  "tumors." 

CASE  1. — A  farmer  aged  thirty-four  came  to  the  hospital  because 
of  pain  and  sw^elling  under  the  jaw. 

History. — A  week  ago  while  pitching  wheat  a  beard  from  the  wheat 
found  its  way  under  his  tongue.  He  removed  it  at  once  but  the  irri- 
tation did  not  leave.  At  night  he  discovered  that  a  point  had  re- 
mained. This  was  removed  by  his  doctor.  He  felt  relieved  for  a 
day,  then  he  began  to  have  pain  under  his  jaw.  This  had  gradually 
increased  during  the  time  and  the  swelling  has  kept  pace. 


!!)() 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


Examination. — There  is  an  indurated  mass  beneath  the  angle  of 
the  jaw  which  extends  upward  over  the  parotid  and  beyond  the  median 
line  (Fig.  102).  It  is  hard  to  the  touch  and  painful.  The  infection 
does  not  elevate  the  floor  of  the  mouth  and  the  larynx  is  not  edema- 
tous.    The  patient's  temperature  is  102°. 

Diagnosis. — The  rapidity  of  its  onset,  the  fever  and  the  sensitive- 


Fig.   102.^ — Abscess  of  the  neck  due  to  infection  from  within  the  floor  of  the  mouth. 


ness  to  pressure  distinguish  it  as  an  abscess  rather  than  a  woody 
phlegmon  wliich  would  give  the  same  phj'sical  characteristics. 

Treatment. — Incision  at  a  point  which  was  estimated  would  bring 
the  scar  under  the  angle  of  the  jaw.  An  abscess  containing  a  dram 
of  pus  was  drained. 

After-course. — The  pain  disappeared  and  the  swelling  rapidly  sub- 
sided. 

Comment.—Sueh  cases  should  be  drained  wide  and  earlj-  for  fear 
of  extension  dowii  the  neck  to  the  mediastinal  space  or  toward  the 


DISEASES   OF    THE   NECK  191 

larynx,  producing  edema.  These  cases,  when  it  is  certain  there  is  no 
pointing  into  the  mouth  or  pharynx  where  spontaneous  rupture  may 
occur,  are  best  done  under  a  general  anesthetic. 

CASE  2. — A  retired  farmer  aged  sixty-five  came  to  the  hospital 
because  of  a  swelling  of  the  neck  and  inability  to  open  his  mouth. 

History. — Ten  days  ago  pain  began  under  the  corner  of  his  jaw. 
There  was  pain  on  pressure  at  this  point.  He  was  unable  to  open  his 
mouth  more  than  half  an  inch.  The  swelling  in  the  neck  has  increased 
until  the  whole  neck  to  his  collar  bone  is  painful.  He  has  had  some 
fever  from  the  beginning,  going  at  one  time  to  103°.  The  pain  has 
been  so  severe  that  he  had  been  unable  to  sleep  and  he  has  taken  only 
small  amounts  of  liquid  nourishment. 

Examination. — The  entire  right  side  of  his  neck  is  swollen  and  hard 
and  it  is  very  sensitive  to  touch.  There  is  no  definite  site  of  maximum 
reaction  and  no  fluctuation.  The  left  side  is  unaffected.  He  is  una- 
ble to  open  his  mouth  more  than  half  an  inch.  The  posterior  end 
of  the  lower  jaw  is  much  swollen  and  red  and  very  sensitive  to  pres- 
sure with  a  spatula.  The  wisdom  tooth  is  absent.  The  patient  states 
that  he  never  had  one.  The  temperature  is  102°,  pulse  110,  respira- 
tion 26.    W.b.c.  26,000. 

Diagnosis. — A  diffuse  swelling  in  the  neck  with  marked  limitation 
of  movement  of  the  lower  jaw  must  come  from  a  process  involving  the 
masseter  muscle.  The  absence  of  a  wisdom  tooth  and  the  marked 
swelling  in  this  region  marks  this  as  the  site  of  origin  of  the  inflamma- 
tory process.  Notwithstanding  the  absence  of  palpatory  evidence  of 
localized  suppuration,  the  general  condition  is  such  that  its  presence 
must  be  assumed. 

Treatment. — An  incision  two  inches  or  more  in  length  was  made 
along  the  anterior  border  of  the  sternomastoid  muscle.  When  the 
plane  below  the  muscles  was  reached  a  considerable  amount  of  pus 
was  discovered.  Ail  the  tissue  below  the  platysma  was  markedly 
edematous.    The  wound  was  packed  with  gauze. 

Pathology. — No  less  than  six  varieties  of  bacteria  were  plated  among 
which  was  a  staphylococcus. 

After-course.— The  swelling  rapidly  subsided.  It  required  two 
months  before  the  jaw  could  be  opened  wide  enough  to  permit  the 
extraction  of  the  tooth.    It  lay  parallel  with  the  level  of  the  alveolar 


192  CLINICAL   SURGERY    BY    CASE   HISTORIES 

border  and  its  crown  impinged  against  the  tooth  lying  in  front  of  it. 
Recovery  was  complete  after  the  removal  of  the  tooth. 

Comment. — The  infection  was  a  diffnse  cellulitis  and  not  a  lymph 
gland  infection.  This  made  prompt  and  wide  incision  imperative  in  or- 
der to  prevent  extension  of  the  infection  into  the  mediastinum.  This 
done  the  process  was  limited  to  the  region  of  the  jaw.  To  have  re- 
moved the  tooth  at  the  time  of  tlie  incision  into  the  neck  would  have 
required  an  external  incision  with  consequent  scarring. 

CASE  3. — A  farmer  aged  thirty-four  came  to  the  hospital  because 
of  an  infection  of  the  neck. 

History. — Two  months  ago  his  right  upper  wisdom  tooth  began  to 
pain.  A  dentist  made  several  attempts  to  extract  it.  A  second  den- 
tist succeeded  in  removing  it  three  days  later.  Soon  after  the  first 
attempt  he  began  to  have  pain  in  the  neck  below  the  jaw.  This  pro- 
gressed slowl}^  until  the  whole  side  of  the  neck  was  swollen.  He  had 
a  low  fever  and  marked  loss  of  appetite.  The  pain  Avas  constant  but 
not  severe. 

Examination. — The  right  side  of  the  neck  from  al)ove  the  mastoid 
process  and  medially  to  beyond  th(>  trachea  is  markedly  swollen.  The 
swelling  is  hard  yet  somewhat  springy.  It  is  somewhat  sensitive  on 
deep  pressure.  Tlie  advancing  border  is  not  apparently  elevated, 
but  on  palpation  there  is  a  hard  ridge  not  unlike  the  border  of  an  ery- 
sipelas only  much  more  pronounced.    It  is  too  dense  to  pit. 

Diagnosis. — The  slowly  progressive  character  of  the  lesion  with  the 
thick  tumor-like  thickening  suggested  a  woody  phlegmon  since  it 
lacked  the  more  acute  symptoms  of  Ludwig's  angina. 

Treatment. — In  order  to  be  sure,  tlie  mass  was  deeply  incised.  The 
subcutaneous  tissue  was  dense  and  glassy.  It  showed  but  little  ten- 
dency to  bleed  and  there  was  no  pus. 

Pathology. — A  culture  of  cocci  was  obtained  which  failed  to  show 
the  characters  of  any  of  the  familiar  forms.  On  section  the  mass  is 
compo.sed  of  a  rich  cellular  mass  not  unlike  a  small  round-celled  sar- 
coma (Fig.  103).  Many  areas  of  polynuclear  infiltration  are  found. 
At  the  border  these  cells  follow  in  the  edematous  connective  tissue 
spaces.    Evidently  the  edema  precedes  the  cellular  infiltration. 

After-course.- — The  lesion  gradually  extended  downward  over  the 
chest  and  across  to  the  unaffected  side  of  the  neck.    He  became  septic, 


DISEASES   OF    THE   NECK 


193 


sliowed  signs  of  delirium  with  progressive  dyspnea.    These  symptoms 
gradually  increased  until  he  died. 

Comment.— The  interesting  feature  is  the  slowly  progressive  course, 


■Woody  phlegmon,  of  the  neck. 


and  the  peculiar  abundance  of  a  lymphoid  type  of  cells.  A  cursory 
glance  at  the  section  suggests  sarcoma.  A  closer  study  shows  in  addi- 
tion much  granular  fibrin  and  many  polynuclear  leucocytes. 

CASE  4.— A  merchant  of  fifty-two  came  because  of  an  inflamma- 
tory affection  of  his  neck. 

History. — Two  weeks  ago  he  began  to  have  pain  on  swallowing 
and  noticed  a  swelling  in  his  neck  below  the  angle  of  the  jaw  which 
was  very  painful  on  pressure.  His  physician  applied  iodine,  but 
the  condition  has  become  gradually  worse,  until  now  the  whole  side 
of  the  neck  and  floor  of  the  mouth  is  painful.  He  has  never  had 
anything  of  the  sort  before. 

Examination. — There  is  a  bulging  below  the  border  of  the  jaw 
which  is  painful  on  palpation.     The  skin  is  not  reddened  and  is  mov- 


194 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


able  oil  the  underlying  mass.  The  chief  part  of  the  swelling  pro- 
jects into  the  mouth  (Fig.  104).  There  is  a  palpable  ridge  between 
the  tongue  and  maxilla  which  is  extremely  sensitive.  The  alveolar 
border  is  not  affected  and  the  affection  does  not  seem  to  be  focused  at 
any  one  point  and  there  is  no  fluctuation.  The  mucosa  was  cocainized 
and  the  prominent  ridge  was  sounded  with  a  fine  round  needle.  Half 
an  inch  from  the  frenulum  a  solid  object  is  struck. 

Diagnosis. — The  normal  color  of  the  skin  and  its  mobility  separated 


Fig.    104. — Infection   of  the  floor   of  the   mouth   clue   to   a   sialolith. 


the  affection  from  an  infective  cellulitis.  The  peculiar  ridge-like 
swelling  suggested  the  presence  of  a  sialolith  which  was  proved  by 
the  needle. 

Treatment. — An  incision  was  made  over  the  point  where  the  needle 
encountered  resistance,  and  a  stone  turned  out. 

Pathology. — The  stone  was  bean-shaped  15  by  10  by  7  mm.  It  was 
slightly  roughened  and  of  a  yellowish  brown  color. 

After-course. — The  inflammation  quickly  subsided  and  the  patient 
has  remained  well. 


DISEASES    OF    THE    XECK  195 

Comment. — This  disease  is  usually  oTerlooked  because  the  surgeou 
does  not  think  of  the  possibility.  It  is  the  ridge-like  mass  independ- 
ent both  of  the  jaw  and  tongue  that  should  suggest  such  a  condi- 
tion. The  cellulitis  is  sometimes  extensive,  but  the  skin  is  never  in- 
volved as  in  a  true  cellulitis  of  the  floor  of  the  mouth.  Abscess  does 
not  form.  The  x-ray  may  be  used  to  locate  the  trouble,  but  when  the 
stone  is  small,  it  may  not  show  on  the  picture. 

CASE  5. — A  young'  farmer  aged  twenty-eight  came  to  the  hospital 
because  of  periodical  swelling  over  his  lower  jaw. 

History. — For  eight  years  he  has  had  periodic  pains  and  gatherings 
over  the  right  jaw  near  the  ear.  It  never  has  had  to  be  opened.  Some- 
times after  the  swelling  reaches  its  height  it  suddenly  goes  down 
and  he  is  relieved  for  a  time. 

Examination. — The  parotid,  particularly  its  anterior  portion,  is 
swollen  and  tender.  He  is  able  to  open  his  mouth  but  little  more 
than  half  an  inch.  After  a  considerable  effort  a  fine  probe  (stylet 
from  a  hypodermic  needle)  is  passed  into  Stenson's  duct  and  a  stone 
can  be  felt. 

Diagnosis. — The  swelling  seems  to  involve  the  parotid  gland  and 
to  be  limited  to  it.  The  limitation  of  movement  of  the  jaw  must  be 
due  to  irritation  of  the  masseter  muscle.  It  is  not  clear  how  a  sialolith 
in  the  duct  could  cause  such  a  swelling  of  the  parotid  and  so  little 
at  the  site  of  the  stone.  The  history  of  sudden  subsidence  of  pain 
seems  to  be  explainable  by  assuming  the  release  of  dammed-up  secre- 
tions. 

Treatment. — The  duct  is  slit  open  half  an  inch  with  a  cataract 
knife  but  a  stone  could  not  be  discovered. 

After-course. — The  patient  has  been  free  from  recurrence  now  three 
years.     The  obstruction  must  have  been  only  cicatricial. 

Comment. — Stone  in  this  duct,  as  compared  to  the  submaxillary, 
is  very  uncommon.  Symptoms  may  be  caused  by  constriction  of  the 
duct  without  stone.  At  least  cases  are  observed  in  which  no  stone 
can  be  found  and  opening  the  duct  relieves  of  the  symptoms. 

Note. — After  the  above  was  written  there  was  a  violent  recurrence 
of  the  trouble  with  involvement  of  the  deeper  tissues  of  the  neck.  An 
x-ray  disclosed  a  malerupted  wisdom  tooth,  the  removal  of  which 
cured  him  once  more — this  time  I  believe  for  good.     The  inabilitv 


196  CLINICAL   SURGERY    BY    CASE   HISTORIES 

to  open  the  moutli  should  have  put  me  on  the  right  track  before. 
A  simple  damming-iip  of  secretions  in  the  parotid  would  not  affect 
the  muscles  of  mastication  sufficiently  to  have  limited  the  movements 
of  the  jaw.    I  am  sure  I  have  made  this  error  before. 

CASE  6. — A  fanner  aged  sixty-eight  came  to  the  hospital  because 
of  a  sore  throat  and  sw^elling  under  his  jaw. 

History. — Three  weeks  ago  the  patient  had  a  chill  which  lasted 
several  hours  and  was  followed  by  profuse  sweating.  He  has  had  a 
tendency  to  chill  since  when  exposed  to  the  air.  The  day  following 
the  chill  his  throat  became  sore  and  the  soreness  has  persisted.  A 
few  days  later  a  swelling  developed  in  his  neck.  For  the  past  week 
fluid  runs  out  of  the  nose  when  he  attempts  to  drink.  He  is  very  weak, 
has  palpitation  when  he  moves  about,  has  complete  anorexia  and  a 
persistent  headache. 

Examination. — The  patient  presents  the  appearance  of  being  very 
sick.  He  lies  with  his  mouth  partly  open  and  fluid  trickles  out  of 
it.  A  swelling  is  noted  under  the  jaw  which  on  palpation  shows 
several  glands  the  size  of  a  pigeon's  egg.  The  mouth  can  be  opened 
only  imperfectly.  On  the  anterior  pillar  and  over  the  posterior  por- 
tion of  the  toothless  lower  jaw  is  an  ulcer  half  an  inch  by  an  inch 
and  a  half  in  extent.  It  is  undermined  with  a  ragged  wall  and  a 
dirty  gray  base.  The  soft  palate  and  uvula  are  edematous.  The 
tonsil  itself  is  hidden  by  the  swollen  anterior  pillar  and  when  for- 
cibly exposed  shows  but  a  general  redness.  The  patient  has  a  dilated 
heart  with  a  systolic  apical  murmur  and  an  accentuated  second 
sound.     The  urine  contains  albumin  and  hyaline  casts. 

Diagnosis. — The  acute  onset  and  the  ulcer  with  glandular  involve- 
ment indicate  some  acute  infection.  I  had  not  seen  such  a  picture 
before,  but  a  swab  from  the  ulcer  showed  an  abundance  of  Yin- 
cent's  spirilla.     The  diagnosis  therefore  was  Vincent's  angina. 

Treatment. — The  ulcerous  area  was  painted  twice  a  day  with 
tr.  iodine  and  glycerine,  equal  parts.  The  patient  was  much  im- 
proved in  a  week. 

After-course. — Subsequent  observation  indicated  that  his  heart 
trouble  as  well  as  his  al])umin  was  of  ancient  date  and  he  retained 
them  after  his  throat  trouble  disappeared. 


DISEASES    OF    THE    NECK  197 

Comment. — This  disease  is  generally  overlooked.  An  ulcerous 
lesion  calls  for  a  microscopic  study  of  its  secretions.  Usually  the 
disease  responds  with  astonishing  promptness  to  iodine.  One  must 
guard  against  overlooking  some  associated  disease.  I  once  saAV  it 
as  the  terminal  disease  in  a  pernicious  anemia  which  had  previously 
been  recognized,  and  once  in  leukemia  in  which  a  good  prognosis 
was  given  because  the  leukemia  was  overlooked. 


CHAPTER  VI 

DISEASES  OP  THE  THYROID  GLAND 

NONTOXIC  DISEASES  OF  THE  THYROID 

Enlargements  of  the  thyroid  may  be  either  functional  hypertro- 
phies or  neoplastic  formations,  and  in  considering  their  clinical  as- 
pects, both  possibilities  must  be  considered.  The  so-called  innocent 
goiter  may  present  the  pressure  problems  of  a  benign  tumor,  with  the 
potential  of  becoming  a  malignant  one,  and  it  may  at  any  time  mani- 
fest a  perverted  activity  and  become  toxic.  There  is  no  such  thing 
as  an  innocent  goiter,  an}*  more  than  there  is  innocent  dynamite. 

CASE  1. — A  farmer  aged  sixty  came  to  the  hospital  for  relief 
from  a  goiter. 


Fig   105. — Huge   colloid   goiter. 

History. — The  patient  has  had  a  goiter  for  forty-four  years.  It 
grew  gradually  but  slowly  for  many  years,  but  has  developed  rapidly 
during  the  last  few  years.     Aside  from  the  inconvenience  of  its  size, 

198 


DISEASES    OF    THE    THYROID    GLAXD 


199 


he  lias  not  suffered  from  it.    He  desires  its  removal  because  its  pres- 
ence limits  the  movements  of  his  head. 

Examination. — A  huge  thyroid  surrounds  his  neck  acting  as  a  jury 
mask  (Fig.  105).  His  chin  is  held  permanentl}"  aloft.  Eotation  is 
not  hindered.  The  goiter  is  fairly  firm  hut  not  hard.  Veins  the  size 
of  a  finger  are  visible  under  the  skin.  The  superior  thyroid  vessels 
are  seen  and  felt  as  huge  pulsating  cords  reminding  one  of  the  feel 
of  the  brachial  artery  in  aortic  regurgitation.  The  mass  is  movable 
around  the  neck.  The  sensation  imparted  to  the  examiner  recalled 
that  experienced  in  adjusting  a  horse  collar. 


Fig.    106. — Section   of  a   colloid   goiter. 

Diagnosis. — The  feel  of  the  mass  is  firm  and  little  elastic.  That  it 
is  a  colloid  goiter  is  substantiated  by  the  great  size  and  long  duration. 
The  only  question  which  presents  itself  is  the  risk  in  its  removal. 
The  large  size  of  the  vessels  and  the  hardness  of  their  Avails  made  the 
question  of  their  ligation  a  pertinent  one.  AYhile  the  vessels  are  huge, 
there  is  no  evidence  but  that  their  ligation  would  be  successful,  since 
neither  these  nor  the  vessels  elsewhere  in  the  body  are  unduly  ather- 
omatous. Generally  speaking  the  large  colloid  goiters  of  long  dura- 
tion are  easy  of  removal. 

Treatment. — The  right  lobe  and  isthmus  Avere  removed  at  the  first 
sitting.     During  the  interval  between  the  first  and  second  operations 


200  CLINICAL    SURGERY    BY    CASE    HISTORIES 

the  lobe  remaining  had  descended  so  that  instead  of  occupying  its  nor- 
mal position  on  the  side  of  the  neck  it  had  come  to  lie  transversely 
across  the  neck.  Three  weeks  after  the  first  operation  four-fifths  of 
the  remaining  lobe  were  removed.  Both  operations  were  simple  of 
execution.    The  large  size  of  the  vessels  made  their  localization  easy. 

Potholof/ji. — The  combined  weight  of  the  two  lobes  Avas  four  pounds. 
The  section  showed  huge  areas  of  colloid  divided  into  small  lobes  by 
septffi  with  here  and  there  patches  of  cystic  degeneration  (Fig.  106). 

After-course. — Healing  was  uneventful.  After  he  recovered  from 
the  operation  he  showed  slight  mental  aberration.  It  was  thought  the 
disturbance  in  circulation  caused  by  the  deranging  of  so  large  a  res- 
ervoir near  the  brain  Avas  the  cause  of  it.  On  inquiry  a  relative 
some  weeks  later  relieved  us  by  the  information  that  he  had  shown 
these  peculiarities  for  some  A^ears. 

Comment. — Very  large  goiters,  particular!}^  those  of  long  dura- 
tion, are  easy  to  operate  because  they  are  dislocated  by  their  size.  In 
the  process  of  dislocation  the  A'essels  are  made  more  prominent.  In 
this  dislocation  the  recurrent  laryngeal  nerves  are  sometimes  aston- 
ishingly misplaced  and  resection  may  be  made  difficult  because  the 
two  poles  are  so  widely  removed  from  each  other.  In  such  cases  it 
is  best  to  do  a  clean  dissection,  ligating  each  vessel  cautiously  until 
the  nerve  is  located.    It  can  then  be  avoided. 

CASE  2. — A  matron  of  fifty-two  came  to  the  hospital  because  of  a 
large  goiter. 

History. — Slie  has  had  a  goiter  thirty-two  years.  It  has  caused  no 
trouble  until  recently.  She  has  a  shortness  of  breath  which  she  as- 
cribes to  the  goiter  because  when  lying  down  the  breathing  is  relieved 
if  she  can  arrange  her  pillows  in  a  certain  way.  The  breathing  is  not 
disturbed  by  ordinary  exertion,  but  when  exertion  is  combined  with 
stooping  or  leaning  backward  she  has  trouble  in  getting  her  breath. 
Her  general  health  is  good. 

Examination. — She  has  a  very  large  goiter  which  displaces  the  tra- 
chea markedly.  It  is  unusually  firm  but  elastic.  It  can  be  freely 
moved  about,  but  manipulation  produces  a  cough.  The  mass  rides  on 
the  clavicle  and  presses  under  the  jaw.  The  heart  shows  no  abnor- 
malities. 


DISEASES    OF   THE    THYROID    GLAND 


201 


Fig.    107-A. — Gross  appearance    of   a  fibrous   goiter. 


WS,  'S 


>'>^>'X:  ^'^/fe' 


.!    ' 


'•   -V-    ^        ■      ■■  •""-^'^  .1^Yv•v     nr«fc  t!- ■•  . 


Fig.  107-B. — Slide  of  the  preceding  showing  the  large  amount  of  a  cellular  fibrous  tissue. 


202  CLINICAL   SURGERY   BY    CASE    HISTORIES 

Diagnosis.- — The  goiter  seems  to  cause  disturbance  only  because  of 
its  size.  With  any  change  of  position  it  is  forced  against  the  trachea. 
The  problem  is  that  of  a  mechanical  hindrance. 

Treatment. — A  simple  lobectomy  was  done. 

PdtlioJogij. — A  cross  section  of  the  tumor  shows  it  to  be  composed 
of  fibrous  tissue  (Fig.  107 -A)  with  a  number  of  small  cysts  containing 
clear  fluid  imbedded  in  it.  About  the  periphery  the  ghmd  sul)stance 
in  a  state  of  colloid  degeneration  is  retained.  In  several  parts  of  this 
there  is  a  hemorrhagic  infiltration.  The  slide  (Fig.  107-5)  shows  a 
dense  fibrous  tissue  with  nests  of  compressed  gland  tissue.  The  gland- 
ular portion  showed  ordinary  colloid  degeneration. 

After-course. — Recovery  was  prompt  and  the  d3'spnea  Avas  relieved. 

Comment. — This  is  the  most  "innocent"  goiter  I  have  ever  seen. 
Save  as  a  mechanical  factor,  it  was  capable  of  little  mischief.  It 
shows  in  an  exaggerated  form  the  spontaneous  obliteration  of  gland 
substance. 

CASE  3. — A  woman  ag"ed  seventy  came  to  the  hospital  because  of 
a  persistent  cough. 

History. — She  has  coughed  for  thirty  years.  It  has  varied  in  inten- 
sity, but  tins  has  not  been  dependent  on  any  particular  time  of  the 
year  or  any  definite  circumstances  except  that  it  was  worse  when 
she  had  a  cold.  During  the  past  few  weeks  it  has  been  aggravated 
by  such  an  event.  It  is  worse  the  fore  part  of  the  night  and  she  has 
a  spell  in  the  morning  after  getting  up.  At  this  time  sputum  is  more 
abundant  than  any  other  time  of  the  day,  but  she  raises  some  during 
the  day  the  most  of  the  time.  The  mucus  raised  is  a  dirty  gray,  ex- 
cept in  the  morning  it  is  wdiiter  and  more  foamy. 

She  has  spells  of  distress  and  heaviness  in  the  epigastrium  follow- 
ing meals  and  has  to  be  careful  what  she  eats.  Is  obstinately  consti- 
pated and  the  stomach  symptoms  improve  after  catharsis.  She  has 
lost  42  pounds  in  weight  during  the  last  year. 

She  has  had  a  tumor  of  the  neck  for  thirty  years.  It  has  grown 
gradually.  It  does  not  interfere  with  respiration  now,  but  several 
years  ago  it  caused  a  choking  sensation  at  night.  She  has  had  a 
rapid  heart  now  for  the  past  year.  She  has  had  the  goiter  treated 
both  by  outside  application  and  injection  of  medicine  into  the  goiter 
substance. 


DISEASES    OF    THE    THYROID    GLAND  203 

Examination. — The  patient  is  a  small,  stooped,  much  emaciated 
woman  weighing  scarcely  a  hundred  pounds.  Respiration  is  some- 
what labored.  Talking  visibly  tends  to  bring  on  coughing  spells. 
Much  effort  is  required  to  produce  a  glairy  dirty  whitish  gray  mucus. 
The  dysjinea  seems  to  be  both  inspiratory  and  expiratory.  She  has 
a  medium  large  goiter,  both  lobes  and  isthmus  being  enlarged.  A 
large,  spheroid  tumor  occupies  the  isthmus;  the  goiter  is  firm  and 
fairly  well  fixed. 

The  chest  is  barrel  shaped.  The  right  lung  is  less  resonant  than 
the  left,  particularly  in  the  region  of  the  fourth  rib  in  front  and  the 
seventh  behind.  The  breathing  is  somewhat  tubular  in  this  region. 
The  left  lung  behind  at  its  lower  border  is  somewhat  flat.  There  are 
medium-sized  moist  rales  over  the  whole  of  the  right  lung  and  at  the 
base  of  the  left  one.  These  findings  varied  in  the  different  examina- 
tions made.  The  apex  of  the  heart  is  displaced  outward  and  down- 
M^ards,  the  pulse  is  full  and  bounding  but  there  are  no  murmurs. 
The  x-ray  shows  radiating  shadows,  particularly  in  the  right  side,  be- 
ginning at  the  liilus  and  extending  outward  and  downwards. 

Diagnosis. — She  has  a  goiter,  a  chronic  bronchitis  with  bronchiec- 
tasis. The  problem  to  determine  is  the  relation  of  the  goiter  to  this 
syndrome  and  to  calculate  the  effect  of  the  removal  of  the  thyroid. 
The  dyspnea  apparently  is  an  obstructive  one.  The  size  and  con- 
sistency of  the  goiter  makes  it  well  calculated  to  exert  a  pressure  on 
the  trachea.  Whether  or  not  the  rapid  pulse  and  tremor  is  the  result 
of  her  general  condition  or  from  a  secretion  of  the  gland  is  more  dif- 
ficult to  estimate.     The  determination  of  this  must  be  awaited. 

Treatment. — The  patient  was  placed  in  bed  and  given  ammonium 
chloride  internally  and  creosote  and  benzoin  inhalations  twice  daily. 
The  cough  improved  under  this  treatment  and  the  pulse  came  down 
to  72  to  90.  After  three  weeks  of  this  treatment  the  right  lobe  of 
the  thyroid  was  removed.  After  the  lobe  was  dislocated  the  trachea 
was  found  to  be  much  flattened  and  care  had  to  be  exercised  in  order 
to  avoid  the  compression  of  it  during  the  manipulations.  There  was 
an  area  of  calcification  at  its  medial  lower  border. 

Pathology. — The  gland  was  made  up  of  large  amounts  of  colloid 
with  some  areas  of  hemorrhagic  infiltration. 

After-course. — The  dyspnea  disappeared  at  once  after  the  removal 
of  the  thyroid.     The  distressing  morning  cough  disappeared  as  if  by 


204  CLINICAL   SURGERY   BY    CASE    HISTORIES 

magic.     She  gained  rapidly  in  weight  but  some  expectoration  con- 
tinues, particularly  in  the  morning. 

Comment. — Unquestionably  the  compression  of  the  trachea  was  the 
cause  of  her  dyspnea.  Whether  this  may  account  for  her  bronchi- 
ectasis or  not  is  difficult  to  say.  The  general  improvement  has  been 
so  pronounced  that  it  seems  quite  likely  that  there  was  some  toxic  se- 
cretion of  the  gland. 

CASE  4. — A  housewife  aged  fifty-eight  came  to  the  hospital  be- 
cause of  a  tumor  of  the  neck  and  difficulty  in  breathing-. 

History. — The  patient  has  had  a  goiter  twenty-five  years.  It  has 
attained  gradually  its  present  size.  She  does  not  believe  it  has  grown 
more  rapidly  in  recent  months  but  it  seems  to  fit  more  tightly  result- 
ing in  restricted  freedom  of  movements  and  sometimes  in  dyspnea. 
This  is  most  marked  when  she  lies  down.  It  troubles  least  when  she 
lies  on  a  high  pillow  and  points  her  chin  downward  and  to  the  right. 
There  is  no  trouble  in  swallowing,  but  there  is  some  trouble  in  her 
speech.  She  has  five  grown  children  and  has  never  had  any  illness 
of  any  sort. 

Examination. — The  front  of  the  neck  is  occupied  by  a  bosselated 
tumor  mass.  The  mass  in  the  right  side  is  as  large  as  an  orange,  the 
surface  is  hard,  particularly  its  medial  surface,  which  is  stony.  The 
left  side  is  the  size  of  a  large  lemon  and  is  less  dense  than  the  right. 
The  isthmus  is  represented  by  a  mass  the  size  of  an  egg.  The  mass  is 
firmly  fixed  to  the  trachea  and  any  attempt  to  study  its  mobility  rela- 
tive to  the  trachea  and  other  tissues  of  the  neck  precipitates  an  at- 
tack of  dyspnea.  The  general  condition  of  the  patient  is  good.  No 
evidence  of  intoxication. 

Diagnosis. — The  very  dense  feel  indicates  that  the  glands  are  cal- 
cified in  part.  Its  fixity  to  the  trachea  together  with  the  presence 
of  the  dense  area  on  the  medial  lobe  indicates  that  the  gland  is  at- 
tached to  the  trachea  by  calcified  masses.  The  disposition  to  c\yspnea 
when  the  tumor  is  manipulated  shows  that  the  trachea  is  flattened 
either  by  erosion  or  compression  or  both. 

Treatment. — Because  of  the  probable  involvement  of  the  trachea  a 
tracheotomy  tube  and  intubation  set  were  at  hand  before  the  opera- 
tion was  begun.  The  right  lobe  and  isthmus  were  removed.  The 
gland  was  so  closely  attached  to  the  trachea  that  it  was  removed  with 
difficultv.     There  were  calcareous  masses  uniting  gland  and  trachea. 


DISEASES    OF    THE    THYROID    GLAND 


205 


In  making  this  separation  just  above  the  plaques  a  small  artery  was 
severed  which  was  controlled  with  difficulty. 

Pathology. — Many  large  plaques  of  calcareous  material  were  scat- 
tered throughout  the  gland.  Below  and  median  were  areas  sugges- 
tive of  malignancy. 


Tumor 


Fig.    108. — Intratracheal   thyroid.      A.  As    seen   at   operation.      B.  As   it   may   be   conceived   as 

appearing  on  cross  section. 


206  CLINICAL    SURGERY    BY    CASE    HISTORIES 

After-course. — A  year  later  the  patient  returned,  the  left  lobe  hav- 
ing more  than  doubled  in  the  intervening  time.  It  was  nodular  and 
hard.  A  carcinoma  could  be  diagnosticated  Avithout  the  exercise  of 
great  acumen.  This  lobe  was  removed,  albeit  not  without  dii^culty. 
No  symptoms  of  m.vxedema  developed.  She  returned  in  slightly  less 
than  a  year  complaining  of  dyspnea.  Nothing  could  be  seen  or  felt 
to  explain  it,  so  she  was  put  to  bed  for  observation,  but  she  did  not 
appear  to  the  attendants  to  be  suffering.  She  stated,  much  to  my  sur- 
prise, that  she  would  rather  be  dead  than  to  suffer  constant  dread  of 
suffocation.  This  dramatic  statement  from  the  composed  old  lady 
quite  took  me  aback.  I  sought  to  intubate,  but  the  tube  lacked  half 
an  inch  of  going  home.  I  opened  the  trachea  and  found  a  globular 
tumor  filling  it  (Fig.  108).  It  was  attached  for  a  third  of  the  cir- 
cumference of  the  trachea,  about  twice  the  extent  indicated  by  the 
artist.  This  was  excised  with  the  electric  knife  and  the  trachea  closed. 
No  myxedematous  symptoms  appeared  after  this  operation  and  it  was 
evident  that  further  thyroid  metastasis  was  present  somewhere.  The 
mass  removed  showed  malignant  thyroid  tissue.  She  was  free  from 
symptoms  of  any  sort  for  six  months.  At  this  time  a  diffuse  malig- 
nant growth  developed  on  the  left  side  of  the  neck  which  led  to  her 
death. 

Co)iiinent. — In  calcified  glands  which  are  attached  to  the  trachea 
persistent  bleeding  points  often  result  when  the  growth  is  detached. 
These  can  not  be  ligated  and  the  most  effective  way  is  to  touch  them 
with  an  electric  cautery  or  if  this  is  not  at  hand,  a  pledget  of  gauze 
soaked  with  iodine  may  be  pressed  against  them  as  was  done  in  this 
case.  In  these  cases  also  the  trachea  is  often  flattened  and  the  trachea 
may  become  occluded.  Usually  by  the  careful  manipulation  of  the 
gland,  however,  compression  can  be  avoided.  The  fact  that  no 
mj'xedcmatous  signs  developed  after  the  complete  removal  of  the 
gland  was  evidence  that  metastasis  had  already  taken  place.  The 
growth  later  discovered  in  the  trachea  would  have  in  itself  been  suf- 
ficient to  prevent  hypothyroidism.  Though  there  was  a  strong  sus- 
picion at  the  first  operation  that  the  goiter  was  malignant,  a  com- 
plete removal  of  the  gland  was  not  done.  The  history  of  goiter  can- 
cer shows  them  to  be  incurable.  It  is  quite  justifiable,  to  be  sure,  to 
do  a  complete  removal  when  carcinoma  is  known  to  exist.  Once  the 
tumor  has  escaped  from  its  capsule,  requiring  a  section  of  arteries, 
veins  and  nerves  and  even  of  the  trachea  and  esophagus,  the  opera- 


DISEASES    OF    THE    THYROID    GLAND 


207 


tion  clearly  becomes  a  "stunt"  and  is  removed  from  the  legitimate 
field  of  conservative  snrgery. 

CASE  5. — A  boy  aged  ten  years  was  brought  to  the  hospital  be- 
cause of  a  goiter  and  frequent  urination. 

History. — His  general  health  as  a  child  had  always  been  fair.  He 
had  had  frequent  attacks  of  tonsillitis.  In  June  it  was  noticed  that 
he  was  developing  a  goiter.  In  July  his  tonsils  and  adenoids  were 
removed.  In  August  his  vision  became  poor  and  it  was  noticed  that 
he  passed  urine  frequently.     The  amount  was  determined  to  be  24 


Fig.    109. — Goiter   in   a   case   of   diabetes   insipidus. 

pints  in  24  hours.  He  gets  up  frequently  at  night,  which  disturbs 
his  sleep ;  complains  much  of  a  dry  throat,  and  is  losing  weight. 

Examination. — The  boy  is  languid  and  listless.  He  weighs  65 
pounds,  which  is  a  gain  of  4  pounds  in  two  months  instead  of  a 
loss  as  his  mother  surmised.  He  has  a  median  goiter  the  size  of 
an  egg.  It  is  smooth  and  firm.  There  are  no  qjq  signs  or  tremors. 
The  tongue  is  dry  and  inelastic.  The  urine  is  1.002  and  free  from 
foreign  elements.  Pulse  is  76.  The  x-ray  shows  a  normal  sella. 
(Fig.  109.) 

Diagnosis. — The  polyuria  may  be  regarded  as  a  diabetes  in- 
sipidus.    The  x-ray  failed  to  show  any  sellar  change,  but  the  visual 


208  CLINICAL    SURGERY   BY    CASE    HISTORIES 

disturbance  suggests  such  a  possibility.  Despite  the  thyroid  enhirge- 
meut,  his  general  demeanor  suggests  a  hypofunction. 

Treatment. — In  the  absence  of  pituitary  extract  he  was  put  on  a 
grain  of  thyroid  extract  night  and  morning. 

After-course— Re  returned  in  three  weeks.  There  was  no  eliange 
save  he  had  a  tremor  and  distinct  lid  lag.  He  was  put  on  pituitary 
extract  four  grains  a  day.  He  died  a  month  later  from  unknown 
causes. 

Comment. — The  details  of  diagnosis  and  termination  are  lacking, 
but  the  association  of  enlargement  of  the  thyroid  gland,  disturbances 
of  vision,  thyroid  intoxication  after  the  therapeutic  use  of  thyroid  ex- 
tract and  the  early  fatal  termination  makes  it  a  case  not  without  in- 
terest. 

CASE  6. — I  was  called  to  see  a  woman  aged  fifty-eight  because  of 
a  swelling'  of  her  neck. 

History. — Six  months  ago  she  had  a  series  of  chills,  fever,  and  full- 
ness of  the  throat.  Three  months  ago  she  had  some  cough  with  diffi- 
culty in  swallowing.  She  thinks  she  had  fever,  for  she  had  no  appe- 
tite and  lost  in  weight.  From  this  time  she  had  more  or  less  difficulty 
at  intervals  in  swallowing.  A  week  ago  all  efforts  at  swallowing  were 
unavailing.  She  had  fever  and  became  emaciated,  and  lost  weight 
rapidly. 

Examination. — The  patient  gives  the  general  imi^ression  of  acute 
emaciation.  Her  features  are  caved  in  and  she  fairly  hangs  on  her 
pillows.  Her  weight  can  not  exceed  70  pounds.  Her  thyroid  is  uni- 
formly enlarged,  each  lobe  being  as  large  as  an  orange.  The  skin 
over  it  is  red.  To  the  feel  it  is  hot  and  tense  and  the  patient  com- 
plains of  pain  on  pressure.  The  sound  meets  an  obstruction  in  the 
esophagus  in  the  region  of  the  thyroid,  but  can  be  easily  forced  past. 
The  leucocyte  count  is  12,800  with  86  per  cent  polynuclears.  There 
is  no  nervousness,  in  fact  she  is  the  embodiment  of  stoicism.  There 
Ls  no  tremor.  The  urine  is  1030,  no  abnormal  findings.  Her  pulse  is 
120  to  130,  the  temperature  is  99°  to  102°. 

Diagnosis. — The  dyspnea  and  dysphagia  obviously  are  due  to  pres- 
sure from  the  enlarged  thyroid  gland.  The  nature  of  the  enlargement 
is  not  so  easily  determined.  The  redness  of  the  skin  and  the  local 
tenderness  suggests  an  inflammation,  a  subacute  nonsuppurating  thy- 
roiditis.    The  duration  seems  too  long  for  this,  however.     The  leuco- 


DISEASES    OF    THE    THYROID    GLAND  209 

cyte  count  speaks  for  this,  both  the  total  number  and  the  percentage 
of  polynuclears.  The  emaciation  seems  best  explained  on  the  theory 
of  acute  starvation,  rather  than  on  one  of  thyrotoxicosis.  The  gland 
is  very  firm  to  the  touch,  much  firmer  than  is  observed  in  thyrotoxi- 
cosis. 

Treatment. — The  patient  was  fed  regularly  by  means  of  a  tube,  and 
an  ice  bag  was  placed  over  the  neck. 

After-course. — In  ten  days  she  could  swallow  liquids  freely  and  she 
gained  rapidly  in  weight  and  strength.  She  still  had  a  temperature 
of  99°  to  101°  and  a  pulse  of  120.  She  rejected  the  suggestion  that 
the  enlarged  gland  be  aspirated.  She  returned  home  and  I  learned 
in  a  month  that  she  was  gradually  improving.  Two  months  later  I 
was  again  called  in  consultation.  She  was  delirious  and  had  a  sup- 
purating sinus  over  the  highest  point  of  the  right  lobe.  When  she 
attempted  to  swallow  fluids  they  ran  out  of  this  opening.  Obviouslj' 
an  abscess  had  broken  simultaneously  into  the  esophagus  and  through 
the  skin.  This  had  been  going  on  for  ten  days,  I  was  informed.  The 
patient's  tongue  wan  dry  and  leatheiy.  The  pulse  was  running  about 
14)0  to  the  minute.  I  declined  to  see  the  patient  again  unless  she  were 
removed  to  the  hospital.  Her  family  stated  that  her  wish  was  to  die 
rather  than  submit  to  any  operative  procedure,  and  they  desired  to 
accede  to  her  wishes.    She  died  in  two  days. 

Comonent. — The  course  before  final  suppuration  was  unusually 
long.  I  little  thought  at  first  that  it  would  break  down.  I  was  quite 
sure  it  was  of  that  slow  woody  type,  sometimes  diagnosed  sarcoma  by 
credulous  microscopists.  Had  I  fully  appreciated  the  situation  I 
should  have  insisted  on  aspiration.  One  feels  a  hesitancy  in  stirring 
up  an  acute  thyroiditis.  The  fact  that  the  condition  had  been  going 
on  for  six  months  before  I  saw  her,  that  there  was  no  softening  and 
that  it  broke  spontaneously  two  months  later  might  be  held  to  indicate 
that  the  condition  was  nonsuppurative  in  the  beginning  and  only 
became  suppurative  later.  This  does  not  necessarily  follow\  I  have 
seen  cases  in  w^hich  the  gland  was  as  hard  as  bone  and  yet  when  ex- 
plored showed  an  abscess.  Instead  of  mildly  suggesting  the  desirabil- 
ity of  exploration  in  this  case  I  should  have  demanded  it.  The  rela- 
tively low  total  leucocyte  count  and  the  relatively  low  polynuclear 
count  made  me  less  certain  than  I  might  otherwise  have  been  that 
exploration  was  urgently  indicated. 


210  CLIXICAL    SURGERY    BY    CASE    HISTORIES 

CASE  7. — A  fanner  presented  himself  because  of  a  swelling  in 
the  neck. 

History. — Ten  days  ago  the  patient  began  to  have  headache  with- 
out known  cause.  Soon  he  noticed  a  swelling  in  the  neck  which  was 
tender.  All  these  symptoms  increased  until  the  time  he  presented 
himself  for  examination.  He  has  had  no  tonsillitis  or  any  other  sick- 
ness of  Avhich  he  is  aware. 

Examination. — The  patient  has  a  tumor  on  the  right  side  of  the 
neck  just  below  the  hyoid  bone  which  moves  with  the  trachea  in  deg- 
lutition. It  is  the  size  of  a  lemon  and  is  tender  to  the  touch,  but  is 
hard  and  nonpulsating.  His  pulse  is  88  and  temperature  100.2°. 
His  white  count  is  18,000. 

Diagnosis. — The  tumor  is  obviously  the  enlarged  right  lobe  of  the 
thyroid.  Its  rapid  enlargement  and  tenderness  and  the  leueocytosis 
speak  for  a  suppuration.  The  nonsuppurative  type  is  usually  slower 
in  onset,  but  the  leueocytosis  may  be  as  high.  In  suppuration  the 
polynuelears  are  much  increased,  while  in  the  nonsuppurative  type 
the  mononuclears  may  predominate.  The  mass  is  hard  but  that  is 
the  case  when  the  abscess  is  deep  seated,  as  it  usually  is.  The  fever 
curve  frequently  assumes  a  pyemic  curve.  Positive  diagnosis  is 
made  only  by  exploring  the  interior  of  the  gland. 

Treatment. — The  skin  and  muscles  covering  the  highest  point  of 
the  mass  were  infiltrated  with  novocaine :  this  done,  a  larger  needle 
was  substituted  and  plunged  into  the  depth  of  the  tumor.  Pus  was 
produced.     An  incision  was  then  made  and  a  drain  placed. 

After-course. — In  three  days  the  pulse  was  56,  the  temperature 
97.6°.  The  headache  was  severe  for  two  days  following  the  drainage, 
but  was  controlled  by  aspirin.  The  drain  was  removed  in  four  days. 
It  required  a  number  of  months  before  the  gland  had  receded  to  its 
normal  size.    Recovery  was  complete. 

Comment. — This  is  the  most  frank  suppuration  of  the  thyroid  I 
have  seen.  The  disease  is  usually  far  more  subtle.  Usually  fever 
lasts  for  a  number  of  days  even  weeks  before  the  enlargement  of  the 
gland  is  discovered. 

CASE  8. — A  school  girl  aged  eighteen  came  to  the  hospital  be- 
cause of  a  large  goiter. 

History. — When  the  girl  was  three  days  old  her  mother  noticed  a 
lump  in  the  lower  part  of  the  neck  just  above  the  collar  bone  lateral  to 


DISEASES    OF    THE    THYEOID    GLAND  211 

the  windpipe.  It  has  gradually  grown  until  it  is  unsightly.  She  is 
otherwise  well.     Various  treatments  have  been  tried  without  avail. 

Examination. — A  mass  occupies  the  right  and  midline  of  the  neck. 
It  is  the  size  of  a  large  orange.  The  left  lobe  is  the  size  of  an  un- 
liuUed  walnut.  Save  for  this,  she  seems  a  normal  girl.  The  general 
examination  was  wholly  negative. 

Diagnosis. — True  to  form,  this  congenital  goiter  seems  to  spring 
from  the  lower  pole  of  the  right  lobe.  AVith  this  history  and  the  type, 
general  treatment,  despite  the  youth  of  the  patient,  offers  little. 

Treatment. — The  operative  removal  was  undertaken.  As  the  gland 
was  being  dislodged  a  furious  venous  hemorrhage  occurred.  This  was 
disconcerting  both  to  the  patient  and  to  the  operator  so  a  liberal 
gauze  pack  was  placed  behind  the  partly  dislocated  gland  and  the  op- 
eration suspended.  After  five  days  the  patient  was  given  a  general 
anesthetic  and  the  operation  terminated  without  trouble. 

Pathology. — The  tumor  was  made  up  of  colloid  material.  There 
was  no  adenomatous  formation  as  one  would  expect  from  the  history. 

After-course. — Despite  the  fact  that  the  incision  in  the  soft  parts 
was  kept  open  five  clays  by  the  pack,  healing  was  smooth  and  unevent- 
ful, and  the  line  of  union  not  markedly  conspicuous. 

Comment. — This  was  my  first  goiter  operation.  The  fault  lay  in 
trying  to  shell  out  the  gland  before  the  line  of  cleavage  had  been 
accurately  located.  This  resulted  in  the  tearing  of  important  vessels, 
probably  the  middle  vein  of  Kocher.  The  location  of  the  line  of 
cleavage  is  not  easy,  but  it  is  the  most  important  step  in  the  operation. 
This  case  is  detailed  so  that  the  beginner  may  see  that  if  severe  hem- 
orrhage is  encountered,  tamponing  may  control  the  situation.  It  il- 
lustrates well  the  old  saying  that  "he  who  fights  and  runs  away  may 
live  to  fight  another  clay."  An  ignominious  retreat  is  better  than  a 
dead  patient.  Many  patients  are  lost  because  the  operator  persists 
after  he  is  lost  anatomically. 

CASE  9. — A  woman  aged  forty  came  to  the  hospital  because  of  a 
g-oiter. 

History. — The  patient  has  had  a  goiter  for  five  years  and  recently 
has  had  choking  spells  with  rapid  heart.  Menopause  four  years  ago. 
G-eneral  health  has  always  been  good. 

Examination. — A  tumor  as  large  as  a  medium-sized  orange  occupies 
the  right  side  and  median  aspect  of  the  neck.    On  inspection  it  seems 


212  CLINICAL   SURGERY   BY    CASE    HISTORIES 

to  be  a  goiter.  On  palpation  it  is  found  to  be  soft,  semifluctuatino:, 
glides  over  the  deep  muscles  of  the  neck  and  does  not  move  on  deglu- 
tition. 

Diagnosis. — Its  soft  semifluctiiating  feel  and  the  tendency  to 
form  lobulations  at  its  upper  pole  suggests  lipoma.  It  is  evidently 
superficial  to  the  platysma. 

Operation. — Enucleation.  The  tumor  lay  below  the  superficial  fas- 
cia and  platysma  and  upon  the  deep  muscle. 

Patholofjij. — The  tumor  is  a  simple  lipoma. 

After-course. — The  wound  healed  promptly  and  all  the  associated 
symptoms  disappeared. 

Comment. — Owing  to  the  fact  that  the  patient's  doctor  had  diag- 
nosed goiter  and  the  patient  had  full  confidence  that  the  operation 
would  cure,  it  was  thought  best  not  to  disillusion  her  either  before  or 
after  the  operation.  The  sense  of  choking  disappeared.  It  is  diffi- 
cult to  understand  how  any  pressure  on  the  trachea  might  have  been 
caused. 

TOXIC  DISEASES  OF  THE  THYROID  GLAND 

There  is  no  disease  that  offers  the  surgeon  such  a  rich  field 
for  study  as  does  the  perversion  of  the  thyroid  gland.  He  has 
every  advantage  the  internist  and  physiologist  have  and  is  besides 
enabled  to  study  the  changes  wrought  by  lessening  the  blood  supply 
and  from  the  removal  of  a  part  of  the  disease.  The  lure  to  the  ac- 
quisition of  fundamental  knowledge  is  impelling,  for  not  only  is 
the  problem  of  technic  still  far  from  settled  but  the  problem  of 
recognition  of  the  disease  and  its  interrelation  to  other  diseases 
is  ever  present.  Ever.y  nervous  and  nutritional  concomitant  of  sur- 
gical disease  raises  the  question  of  possible  perverted  thyroid 
secretion. 

CASE  1.— I  was  called  to  see  a  girl  aged  eighteen  because  of  fever 
and  delirium. 

History. — The  patient  is  said  to  have  had  good  general  health  save 
for  a  severe  dysmenorrhea,  but  for  the  past  month  or  more  she  has 
been  nervous  and  wakeful,  llather  suddenly  ten  days  ago  she  began 
to  have  fever  and  for  the  past  four  days  she  has  been  delirious  at 


DISEASES    OF    THE    THYROID    GLAND  213 

times.  The  disturbance  was  attributed  to  the  dysmenorrhea,  for  when 
she  tirst  took  to  her  bed  she  did  so  because  of  abdominal  cramps. 

Exaniination. — Tlie  pulse  was  150,  the  apex  bounding  in  the  ante- 
rior axillary  line.  The  eyes  were  protuberant  and  Stellwag's  sign 
was  so  marked  that  intervals  of  a  minute  elapsed  between  involuntary 
winking,  and  Dalrymple's  sign  was  so  marked  that  fully  half  a  cm.  of 
the  conjunctiva  above  the  cornea  was  exposed.  She  had  a  medium- 
sized,  uniform,  soft  goiter  which  pulsated  violently. 

Diagnosis. — Obviously  this  was  a  marked  example  of  thyroid  intox- 
ication. 

Treatment. — Rest  in  bed  with  large  doses  of  bromides,  20  gr.  four 
times  a  day,  were  employed.  The  fever  subsided  gradually,  and  in 
two  months  she  had  a  pulse  of  120  and  was  gaining  in  weight. 

After-course. — AVhile  in  this  state  much  to  my  amazement  she  mar- 
ried. I  warned  her  of  the  probable  disastrous  effect  of  pregnancy. 
Contrary  to  my  dire  predictions,  she  became  pregnant  promptly  and 
promptly  improved.  At  the  termination  of  pregnancy  little  of  the 
thyroid  intoxication  save  the  exophthalmos  remained.  When  she 
menstruated  again,  six  months  after  delivery,  she  did  so  without  pain. 
She  subsequently  went  through  four  more  pregnancies,  the  last  a 
twin,  without  any  recrudescence  of  the  th^a^oid  symptoms.  Recently, 
now  forty-two  years  of  age,  her  menses  have  become  irregular  and  she 
has  hot  flashes,  and  is  again  showing  mild  symptoms  of  thyroid  intox- 
ication and  some  goiter. 

Comment. — It  seems  impossible  to  predict  which  patients  will  be 
markedly  injured  and  which  benefited  by  pregnancy.  We  may  as- 
sume that  the  dysmenorrhea  in  this  case  had  a  deleterious  influence 
on  her  thyroid  gland  and  that  pregnancy,  by  causing  this  to  subside, 
relieved  the  gland  of  this  irritation.  With  the  approaching  meno- 
pause, there  is  a  slight  recrudescence  of  the  thyroid  disturbance.  As 
a  working  basis  it  may  be  assumed  that  those  in  whom  the  thyroid 
disturbance  is  associated  with  dysmenorrhea,  particularly  if  there  is 
an  exacerbation  at  the  menstrual  period,  are  most  apt  to  be  benefited 
by  childbearing.  Those  who  are  neurotic  and  free  from  pelvic  dis- 
orders are  more  apt  to  be  made  worse  by  pregnancy.  Practically,  it 
is  safe  to  advise  all  against  marriage  and  childbearing,  for  one  may 
be  assured  his  advice  will  go  unheeded  if  opportunity  offers,  and  if 
unfavorable  results  follow,  no  blame  will  attend  the  advice. 


214  CLIXICAL    ST'RGERY    BY    CASE    HISTORIES 

CASE  2. — I  was  called  to  see  a  young  woman  because  of  persist- 
ent vomiting. 

History. — The  patient  has  one  brother  who  has  always  been  neu- 
rotic and  was  kept  in  a  private  hospital  several  months  because  of 
melancholia.  The  patient  during  her  girlhood  was  somewhat  nervous 
and  excitable,  but  her  general  health  was  good.  She  has  one  child  two 
years  old.  During  her  pregnancy  she  developed  a  goiter  and  was  ex- 
ceedingly nervous.  After  labor  she  gradually  improved  but  the  nerv- 
ousness and  goiter  persisted.  She  has  now  missed  two  periods  and  for 
the  past  three  weeks  has  vomited  persistently  and  has  become  rapidly 
emaciated.  She  has  become  Aveak  and  exceedingly  nervous  during  this 
period.  Her  chart  shows  a  pulse  rate  of  140-160  and  a  temperature  of 
101-102°.  Her  eyes  have  become  prominent  during  the  past  week. 
She  sleeps  only  when  under  the  influence  of  a  soporific. 

Examination. — There  is  a  medium  soft  symmetrical  pulsating  goi- 
ter. Exophthalmos  is  marked.  Oraefe  and  Kocher  signs  are  pro- 
nounced, pulse  140,  fall  and  bounding.  The  uterus  is  the  size  of  a 
three  months'  pregnancy,  retroverted,  the  cervix  is  soft,  lacerated, 
and  everted.  There  is  a  second  degree  perineal  laceration.  There  is  a 
marked  acetonuria. 

Diagnosis. — The  thyroid  intoxication  and  pregnancy  were  obvious. 
The  diagnosis  has  to  do  rather  with  estimating  the  resistance  than 
with  the  naming  of  the  disease.  The  hyperemesis  seemed  the  dom- 
inating factor  and  the  cause  of  this  likel.v  was  the  pregnancy.  She 
had  some  persistent  vomiting  during  the  first  pregnancy.  Persistent 
vomiting  as  well  as  rise  in  temperature  and  rapid  emaciation  may  at- 
tend acute  thyrotoxicosis.  It  Avas  not  possible  to  determine  definitely 
to  which  factor  the  alarming  condition  was  due.  The  fact  that  the 
goiter  appeared  during  the  previous  pregnancy  made  the  supposition 
that  pregnancy  exercised  a  deleterious  influence  over  her  thyroid 
plausible.  At  any  rate  in  the  face  of  fever,  emaciation,  and  acetonu- 
ria any  operation  on  the  thyroid  Avould  most  certainly  result  fatally. 
The  pregnancy,  in  addition  to  being  the  most  plausible  offending  fac- 
tor, seemed  to  present  possibilities  of  relief  by  interference. 

Treatment. — The  uterus  was  rapidly  emptied.  In  the  hastj^  dilata- 
tion the  cervix  was  lacerated  requiring  a  suture  to  control  the  hemor- 
rhage.    The  fetus  Avas  enucleated  Avith  the  finger. 

After-course. — The  hyperemesis  subsided  promptly  and  the  nervous 
symptoms  subsided  materiallv  but  Avitliout  material   change   in  the 


DISEASES    OF    THE    THYROID    GLAND  215 

goiter  and  exophthalmos  though  the  pulse  came  down  to  around  a 
hundred.  Six  months  later  pelvic  repairs  were  made.  After  that  the 
patient  improved  more  rapidly.  She  continued  to  improve  and  for 
the  past  ten  years  she  has  considered  herself  well,  but  is  still  nervous 
when  "company  comes."  The  eye  signs  disappeared  but  exophthal- 
mos is  still  present  to  a  limited  degree.  The  enlargement  of  the  thy- 
roid has  subsided. 

Comment. — "Where  two  conditions  are  present,  each  capable  of  giv- 
ing rise  to  the  threatening  symptoms,  it  is  advisable  to  attack  the 
factor  which  can  be  made  to  subside  with  the  least  risk  to  the  patient. 
If  this  proves  to  be  the  dominant  factor,  the  fortune  is  so  much  the 
greater.  In  such  cases  it  is  inadvisable  to  delay  interference  by  the 
use  of  temporizing  measures.  In  this  case  the  bromides  and  chloral 
had  been  used  to  produce  sleep  without  in  any  degree  mitigating  the 
hyperemesis.  Since  the  acetonuria  promptly  subsided  when  food  was 
retained,  it  was  obAdously  due  to  starvation  and  not  to  the  th;\Totoxi- 
cosis,  though  thyroid  intoxications  of  this  degree  are  commonly  at- 
tended by  acetonuria. 

CASE  3. — A  woman  aged  forty  came  to  the  hospital  because  of 
dyspnea,  vomiting,  and  goiter. 

History. — The  patient  has  had  three  children.  Her  health  was 
good  until  three  or  four  years  ago  except  that  she  usually  vomited  a 
day  or  two  before  the  menstrual  flow  began.  At  this  time  she  began 
to  have  vomiting  spells  at  times  other  than  the  periods.  She  lost 
weight  rapidly,  going  from  190  pounds  to  90.  It  was  discovered  by 
her  physician  that  she  had  a  pulse  of  130  and  was  developing  a  goiter. 
She  was  treated  by  injections  of  iodine  into  the  substance  of  the  goi- 
ter. Twenty  minims  of  the  tr.  of  iodine  were  injected  into  the  sub- 
stance of  the  gland  at  intervals  of  several  weeks  for  eight  weeks. 
During  this  time  she  gained  38  pounds  in  weight.  During  the  three 
years  since  the  treatment  above  detailed  was  given,  she  has  done 
fairly  well.  Three  months  ago  the  vomiting  became  more  persistent 
and  the  injections  were  repeated  though  without  benefit.  Now  the 
vomiting  begins  a  week  before  menstruation  and  continues  a  week 
afterwards.  Menstruation  itself  is  not  painful  and  lasts  two  days. 
There  is  some  frontal  and  occipital  headache  at  the  beginning  of 
menstruation,  but  none  at  other  times.  She  has  some  leucorrhea, 
particularly  just  before  and  after  menstruation. 


216  CLINICAL    SURGERY    BY    CASE    HISTORIES 

Excuiiinatioii. — There  is  moderate  exophtlialinos  but  no  other  eye 
signs.  There  is  marked  pulsation  of  the  neck,  but  the  gland  itself 
does  not  expand.  There  is  a  moderate  goiter,  bilateral,  quite  firm, 
and  but  little  moval)le.  There  is  marked  tremor.  The  pulse  is  120, 
the  apex  is  diffuse.  There  is  a  moderate  perineal  laceration.  The 
uterus  is  large,  retroverted,  firmly  fixed  by  masses  on  either  side,  and 
there  is  a  small  fibroid  in  the  left  upper  pole.  The  uterus  is  tender  on 
bimanual  examination. 

Diagnosis. — The  diagnosis  of  hyperthyroidism  is  apparent  at  a 
glance.  The  only  problem  is  that  of  interrelation  of  thyroid  and  uter- 
ine symptoms.  The  premenstrual  vomiting  antedated  the  recognition 
of  hyperthyroidism  by  seven  years.  The  hyperthyroidism  was  terri- 
bly toxic  when  first  recognized,  the  patient  having  lost  half  her  weight. 
The  toxic  symptoms  subsided  simultaneously  with  the  rest  in  bed  and 
iodine  injections.  After  three  years  the  symptoms  became  worse,  of- 
ten coincident  with  an  increase  in  the  menstrual  vomiting.  It  is  possi- 
ble that  there  was  present  already  some  thyroid  disturbance  which 
played  a  part  in  the  premenstrual  vomiting  or  that  the  pelvic  dis- 
turbance reacted  on  the  thyroid,  producing  symptoms  of  intoxication. 
It  is  of  interest  to  note  that  the  intraglandular  injection  of  large  doses 
of  tr.  iodine  produced  a  rapid  subsidence  of  the  thyroid  as  well  as  the 
uterine  symptoms.  At  present  both  sets  of  symptoms  are  aggravated. 
On  the  whole  it  seems  that  there  is  an  abnormally  sensitive  endocrine 
system  that  responds  readily  to  a  slight  stimulus.  Since  the  pelvic  le- 
sion is  one  justifying  surgical  treatment  an  attempt  to  break  the  vi- 
cious chain  by  these  means  seems  justifiable. 

Treaimcnt. — Supravaginal  amputation  was  advised  but  rejected. 

After-course. — The  patient  continues  in  a  state  of  semiinvalidism, 
now  better,  noAv  worse. 

Cnm-mcnt. — This  case  illustrates  very  well  the  disposition  to  vomit 
not  infrequently  noted  in  patients  Avith  a  labile  thyroid.  In  such 
cases  operation  on  the  thyroid  itself  is  highly  dangerous.  Conse- 
quently if  any  associated  lesion,  having  any  bearing  on  thyroid  secre- 
tion can  be  discovered  it  should  be  corrected  if  possible. 

CASE  4. — Physician  aged  thirty-six  came  to  the  hospital  because 
of  attacks  of  nausea  and  vomiting'. 

History. — Measles  and  mumps  in  childhood.  Four  years  ago  he 
had  a  spell  of  sickness  in  the  fall  of  the  year  in  which  he  had  nausea 


DISEASES    OP    THE    THYROID    GLAND  217 

and  vomiting  and  diarrhea  accompanied  by  a  fever  of  102-103°.  Sick 
about  ten  days.    No  pain  at  any  time. 

Present  trouble  began  about  two  years  ago  with  a  nausea  that  would 
come  on  him  suddenly.  It  came  on  with  no  particular  regularity. 
They  come  at  intervals  of  one  week  to  six  weeks.  They  come  on  al- 
ways in  the  daytime,  but  were  just  as  apt  to  come  before  meals  as 
after  them.  He  would  lie  down  and  vomit  once,  rarely  more  than 
once,  and  in  fifteen  minutes  get  up  and  go  about  his  work  again.  He 
would  not  have  any  appetite  afterwards,  but  otherwise  felt  all  right. 
He  had  no  pain  whatever  with  the  attacks.  He  was  never  jaundiced 
with  the  attacks  or  afterward.  He  has  had  no  abdominal  distention. 
He  was  almost  always  constipated  before  the  attacks.  No  particular 
food  seemed  to  have  anything  to  do  with  the  attacks.  Vomitus  green 
and  contained  food  particles. 

About  May  1,  1919,  he  noticed  an  increasing  constipation.  He 
felt  all  right  but  he  began  to  take  cathartics  and  could  get  no  bowel 
movement.  He  took  Hinkles,  A.B.S.C.,  and  mag.  sulph.  without  re- 
sults. In  about  three  days  he  became  very  nauseated  and  began  to 
vomit.  He  had  no  pain,  distention  of  the  abdomen  or  temperature. 
Does  not  know  the  pulse  rate.  The  vomitus  at  first  was  bright  green 
and  as  it  continued,  it  became  fecal  in  character.  Vile  taste  and 
smell.  Taste  bitter  and  sour  at  first.  He  vomited  every  half  hour 
or  so  for  4  to  5  days.  It  continued  day  and  night.  Food  taken  was 
vomited.  Even  water  was  brought  up.  At  the  end  of  five  days  he 
took  some  sodium  phosphate  which  for  the  time  settled  his  stomach 
and  he  got  up  and  went  to  the  hospital.  He  felt  all  right  then  for 
a  day  and  a  night  and  did  not  vomit.  He  was  given  some  tablets  and 
the  nausea  and  vomiting  started  again.  He  vomited  for  five  days. 
He  was  given  enemas  and  laxatives  and  finally  his  bowels  moved  for 
the  first  time  since  the  onset  of  his  attack,  an  interval  of  about  ten 
days  without  a  bowel  movement.  As  soon  as  his  bowels  moved  he  was 
relieved  and  went  home.  For  the  next  ten  days  he  did  not  vomit,  he 
ate  some,  his  bowels  moved  about  every  day  with  a  cathartic,  but  he 
did  not  feel  well.  His  nausea  and  vomiting  then  returned  and  he 
vomited  every  fifteen  to  twenty  minutes  for  a  day.  His  bowels  had 
begun  to  become  constipated  the  day  before  and  with  the  second  onset 
again  stopped  moving.  He  vomited  again  for  six  days,  when  they 
again  got  his  bowels  moving  and  he  got  better.  He  then  came  to  Hal- 
stead  Hospital  and  last  night  (6/31/19)  he  was  given  three  Hinkles. 


218  CLINICAL    SURGERY   BY    CASE    HISTORIES 

He  slept  well  but  this  inorning  woke  up  with  nausea  and  vomiting. 
The  vomitus  is  green,  tastes  bitter  and  sour.  He  vomits  frequently, 
fifteen  to  twenty  minutes.  No  pain,  no  rise  of  temperature.  Never 
any  blood  with  vomitus.  Bowels  moved,  stool  white.  Never  noticed 
this  before.  He  has  no  headache,  no  shortness  of  breath  on  exertion, 
no  habitual  cough,  no  edema  of  face  or  extremities,  no  night  sweats. 
He  has  probably  lost  20  pounds  in  the  past  year. 

He  uses  no  alcohol.  Chewed  tobacco  a  great  deal  until  June,  1918, 
when  he  quit  because  he  thought  it  might  affect  his  nausea.  Smoked 
a  good  deal  afterwards,  three  to  six  cigars  a  day. 

Examination. — Pupils  dilated,  react  to  light  and  are  equal  and  reg- 
ular.    No  thyroid  enlargement.     Throat  negative. 

Heart  not  enlarged,  no  murmurs.  Pulse  95,  regular.  Lungs  nega- 
tive. No  tumor  mass  in  abdomen,  no  points  of  abdominal  tenderness. 
Eeflexes,  all  exaggerated.  Patient  has  a  rather  nervous,  restless  ap- 
pearance.   Very  little  or  no  tremor. 

Blood-Hg.  75-80%.  W.b.c,  8,200-8,600-9,600.  R.b.c,  3,648.000- 
3,860,000.  Dif.  Count.  Polys.  42%-46%.  L.L.  6%-6%.-S.L.,  52%, 
48%.    Eos.  2  in  one  slide. 

Gastric — Emesis,  about  50  c.c.  Free  HCl.  35% — Comb,  acidity 
65%.    Urine  1012,  negative. 

X-ray  examination  of  the  gastrointestinal  tract  was  done  twice. 
The  first  time  showed  a  normal  pylorus  and  duodenal  cap,  but  at  the 
end  of  six  hours  there  was  quite  a  retention  of  food  in  the  stomach. 
At  the  end  of  twelve  hours  the  meal  had  passed  to  the  colon.  The 
colon  was  filled  all  the  way,  the  appendix  filled,  and  tlie  colon  showed 
much  spasticity. 

The  second  examination  was  like  the  first,  except  the  stomach  was 
empty  in  six  hours  and  at  the  end  of  12  there  was  still  l)arium  in 
the  terminal  ileum. 

In  the  next  few  days  while  in  the  hospital  the  patient  had  two  at- 
tacks of  nausea  and  vomiting  with  a  three-day  interval  between  them. 
They  lasted  six  to  eight  hours.  There  was  never  any  blood  in  the 
vomitus.    It  seemed  that  the  cathartic  brought  on  the  spells. 

Diagnosis. — In  the  face  of  the  entirely  negative  physical  findings 
and  the  marked  increase  in  the  small  leucocyte  count  and  the  nervous- 
ness of  the  patient  and  the  high  pulse  rate,  always  about  100,  a  diag- 
nosis of  some  disturbance  of  internal  secretion,  most  likely  a  hyper- 
thvroidism,  was  made. 


DISEASES    OF    THE    THYROID    GLAND  219 

Treatment. — Sod.  brom.  gr.  s,  Fl.  Ext.  Hyoscyamus  m.  vi,  t.i.d.  p.c. 
was  given. 

After-course. — He  visited  a  distinguished  clinician,  when  after  a 
thorough  examination,  a  tentative  diagnosis  of  tabes  was  made.  The 
subsequent  course  has  not  made  the  nature  of  the  disease  clear. 

Comment. — This  case  likely  represents  some  disturbance  of  the 
endocrine  system.    Possibly  time  will  clear  up  the  problem. 

CASE  5. — This  patient  ag-ed  twenty-nine  consulted  me  because  of 
persistent  nervousness. 

Uisiorij. — The  patient's  mother  died  from  some  wasting  disease 
soon  after  the  daughter  was  born.  The  patient  has  been  nervous  for 
years.  Since  April  she  has  had  a  shortness  of  breath  and  palpita- 
tion. This  has  gradually  grown  worse.  Her  general  health  has  been 
fair.  She  was  nervous,  sleep  was  not  good,  and  the  appetite  generally 
indifferent.  It  is  better  now  than  usual,  despite  the  advent  of  the 
new  sjmiptoms.  She  has  pain  over  the  eyes  but  no  real  headache. 
The  bowels  moved  ten  to  twelve  times  a  day  for  a  time  but  only  move 
two  to  three  times  now.  The  menstrual  flow  is  scant,  lasting  one  to 
two  days  and  until  just  recentl}^  she  had  not  flowed  for  5  months. 
She  always  has  pain  during  the  flow.  She  has  missed  for  two  or  three 
inonths  at  a  number  of  times.  She  has  more  or  less  pain  over  the 
pubes  and  has  leucorrhea  at  intervals.  This  has  been  nearly  constant 
for  the  past  two  months. 

Examination. — The  patient  is  quite  tall,  flat  chested,  decidedly 
frail  in  appearance.  She  has  recently  lost  15  pounds  and  now  weighs 
less  than  a  hundred  pounds.  There  is  a  moderate  bilateral  enlarge- 
ment of  the  thyroid.  No  eye  signs.  The  pulse  is  140,  bounding,  the 
apex  beat  is  diffuse  and  there  is  marked  tremor  of  the  hands. 

Diagnosis. — Hj'perthyroiclism  can  be  diagnosed  at  a  glance.  Diag- 
nosing the  patient  is  quite  another  matter.  Born  evidently  of  an  ail- 
ing mother  she  has  had  barely  the  vitalit3'  needed  for  existence.  The 
thyroid  enlargement  represents  only  an  additional  burden.  Amenor- 
rhea and  diarrhea  both  bespeak  a  high  degree  of  intoxication.  Ee- 
sistance  for  operation  is  low,  the  recuperative  powers  very  light. 

Treatment. — In  view  of  the  patient's  past  history  and  the  gravity 
of  the  present  condition,  operation  was  refused,  and  the  patient  ad- 
vised to  seek  rest  in  bed  and  sedative  tonic  treatment,  bromides  and 
nux  vomica. 


220  CLINICAL   SURGERY    BY    CASE    HISTORIES 

After-course. — She  improved  somewhat  on  this  treatment  during 
the  following  months.  At  the  end  of  this  time  she  had  a  part  of  the 
right  lobe  of  tlie  thyroid  removed  by  a  competent  surgeon  and  a  month 
later  the  aj^pondix.  Six  montlis  after  the  first  thyroid  operation  a 
portion  of  the  left  lobe  was  removed.  Subsequently  she  was  given 
x-ray  treatment.  Following  this  last  operation  she  gained  15  pounds 
in  weight.  Two  years  later  she  reappeared  complaining  of  much  the 
same  symptoms.  She  had  pain  in  the  lower  abdomen.  She  menstru- 
ates every  five  to  six  weeks  for  ten  to  twelve  days.  The  flow  is  scant 
and  the  suprapubic  pain  persists.  Her  pulse  is  100,  the  heart  still  di- 
lated, and  she  is  able  to  get  about  only  with  great  eifort.  There  is  a 
small  lump  of  thyroid  as  large  as  a  hulled  walnut,  in  the  region  of 
the  left  lower  lobe.  It  is  dense  and  slightly  painful  on  manipulation. 
She  recently  found  a  tumor  of  the  left  breast.  She  has  pain  in  it  before 
menstruation.  Examination  fails  to  show  anything  that  might  be 
regarded  as  a  tumor,  but  the  lireast  is  firm,  cake-like,  a  diffuse  inter- 
stitial mastitis. 

Comment. — It  is  a  question  whether  the  operation  did  the  patient 
any  good.  It  is  my  belief  that  operation  on  the  thyroid  in  neurotic 
substandard  persons  such  as  this  is  ill  advised.  In  reviewing  this 
history,  I  do  not  believe  the  surgeon  who  operated  on  the  patient 
proved  his  point.  Certainly  the  removal  of  the  appendix  with  the 
hope  that  it  would  relieve  the  persistent  suprapubic  pain  was  wholly 
wdthout  justification.  The  patient  now,  though  scarcely  able  to  get 
about,  is  still  seeking  for  further  operative  effort.  True  she  improved 
some,  but  such  patients  do  improve  wdth  simple  rest  and  time.  Noth- 
ing will  save  her  from  being  what  she  always  has  been,  wdiolly  sub- 
standard. 

CASE  6. — A  telephone  operator  aged  twenty-nine  came  to  the 
hospital  because  of  loss  of  appetite  and  digestive  disturbance. 

Historij. — For  a  number  of  months  the  patient  has  had  epigastric 
distress.  This  distress  bears  no  particular  relation  to  meal  time  and 
the  kind  of  food  makes  but  little  difference.  There  has  been  marked 
loss  of  appetite  with  some  vomiting  and  at  times  intense  pain  in  the 
temples.  She  has  lost  15  pounds  in  weight  in  the  past  three  w^eks. 
Recently  she  has  had  a  feeling  of  choking,  i)articularly  when  first 
lying  down.  She  has  been  more  nervous  recently,  which  she  ascribes 
to  the  lack  of  proper  nourishment  due  to  the  stomach  condition.     She 


DISEASES    OF    THE    THYROID    GLAND  221 

sleeps  fairly  well,  but  not  as  well  as  formerh'.  She  dreams  more  and 
does  not  feel  refreshed  when  she  gets  up,  as  formerly.  There  has 
been  no  dizziness.  She  has  long  been  constipated,  but  this  has  been 
aggravated  recently.  Menstruation  is  painful.  The  stomach  trouble 
is  not  aggraA-ated  at  that  time.  Ulcer  has  been  diagnosed  and  she  is 
on  a  diet  in  harmony  witli  this  opinion. 

Examination. — Pulse  134,  full  bounding,  the  apex  beat  is  diffuse, 
there  is  a  pronounced  tremor  of  the  hands.  She  has  a  moderately 
sized  goiter,  particularly  the  right  lobe,  which  extends  under  the 
sternomastoid  as  high  as  the  hyoid  bone  and  well  down  to  the  clavicle. 
The  goiter  is  soft  and  pulsating.  She  had  not  noticed  any  symptoms 
in  the  neck,  save  the  sense  of  choking  above  noted. 

Diagnosis. — The  enlarged  thyroid  together  with  the  rapid  pulse  and 
tremor  are  sufficient  to  classify  the  condition  as  hyperthyroidism. 
The  question  arises  whether  she  may  or  may  not  have  an  affection  of 
the  stomach.  There  is  nothing  but  that  can  be  explained  by  the 
liypersecretion. 

Treatment. — A  general  nerve  sedative  treatment  was  carried  out. 
A  liberal  diet  was  advised. 

After-course. — On  this  treatment  the  symptoms  generally  improved 
and  she  regained  her  weight.  The  goiter  has  not  changed,  though 
the  pulsation  has  lessened.  She  is  not  bothered  by  the  sense  of  chok- 
ing. Her  appetite  and  digestion  are  satisfactory.  Operation  was 
advised,  but  she  feels  confident  improvement  will  continue.  ]\Iost 
likely  she  Avill  improve,  but  relapse  is  also  likely. 

Comment. — AYlien  there  is  any  doubt  as  to  whether  hyperthyroid- 
ism explains  all  the  symptoms  or  not.  it  is  well  to  employ  sedative 
treatment  until  this  point  can  be  determined.  A  thyrotoxic  patient 
may  have  stomach  trouble,  notably  hyperacidity  and  ulcer.  The  at- 
tempt to  meet  these  conditions  by  diet  in  the  presence  of  the  over- 
active goiter  but  aggravates  the  latter  condition.  Actual  hemorrhage 
is  the  only  symptom  that  compels  an  active  ulcer  treatment.  This 
case  should  have  had  a  lobectomy,  for  despite  her  temporary  treat- 
ment a  relapse  is  likely. 

CASE  7. — A  matron  aged  forty-one  came  to  the  hospital  for  relief 
from  a  goiter. 

History. — She  has  six  children  and  had  one  miscarriage  at  three 
months,  twelve  years  ago.     For  the  past  three  years  she  has  had  a 


222  CLINICAL   SURGERY    BY    CASE    HISTORIES 

weak  heart.  It  beats  too  hard  whenever  she  becomes  agitated,  not  so 
on  exertion.  She  has  smothering  spells  during  the  day.  Despite  a 
good  appetite,  she  is  losing  strength  and  weight.  She  gets  trembly 
spells  without  known  cause.    Her  menses  are  regular,  last  two  days, 


A  B 

Fig.    110. — A.  Gross   a|)pearance   of   an   adenomatous    thyroid.      B.  Gross   section   of   the   same. 


Fig.    111. — Microscopic   appearance  of  a   toxic  fetal  adenoma. 

stop  for  a  day  then  flow  two  daj'S  again.  During  the  periods  she  has 
indefinite  abdominal  pain  and  a  constant  dragging  low  in  the  back. 
These  are  made  worse  by  long  standing,  as  in  ironing. 

Examination. — The  patient  seems  well  nourished  and  does  not  dis- 
play the  nervousness  of  which  she  complains.    There  is  a  marked  fine 


DISEASES   OF    THE    THYROID    GLAND  223 

tremor  in  the  hands,  however.  She  has  a  well  circumscribed  nodule 
in  the  isthmus,  the  size  of  a  turkey  egg.  The  lateral  lobes  are  not  en- 
larged. The  pulse  is  124-140,  quick  and  jerky.  The  heart  is  not  en- 
larged. The  uterus  is  large,  retroflexed  and  tender.  There  is  a 
second  degree  perineal  laceration. 

Diagnosis. — There  is  evidently  a  hyperthyroidism  as  indicated  by 
the  nervousness  and  tremor.  There  is  also  an  endometritis  as  evi- 
denced by  the  intermittent  menstruation  and  lower  abdominal  pain. 
The  well  localized  goiter  suggests  itself  as  the  first  line  of  attack. 

Treatment. — -The  circumscribed  area  was  shelled  out  and  the  wound 
closed  without  drainage.  The  lateral  lobes  were  inspected  and  ap- 
peared to  be  normal. 

Pathology. — The  external  surface  is  smooth  and  regularly  ovoid 
(Fig.  110).  The  cut  surface  shows  a  uniform  granular  appearance. 
The  slide  shows  evidence  of  cellular  activity.  The  glandular  increase 
is  much  more  marked  than  the  increase  of  colloid  content  (Fig.  111). 

After-course. — The  nervousness  and  tremor  as  well  as  the  tachy- 
cardia disappeared  so  that  before  she  left  the  hospital  her  pulse  was 
75  to  80.  She  declared  herself  to  be  perfectly  well.  Three  years 
later  save  for  the  distress  at  menstruation  she  had  no  complaints. 

Comment. — This  ease  illustrated  the  prompt  results  which  may  be 
obtained  when  the  sole  cause  of  intoxication  is  confined  within  the 
adenoma  without  involvement  of  the  remainder  of  the  gland.  Had 
this  patient  had  a  small  uniform  goiter,  I  should  have  done  the  pelvic 
repair  first. 

CASE  8. — A  carpenter  aged  thirty  came  to  the  hospital  because 
of  weakness  in  the  knees  and  shortness  of  breath. 

History. — The  patient  has  been  sick  three  and  one-half  months. 
He  noticed  some  shortness  of  breath,  but  has  been  particularly  an- 
noyed by  a  weakness  in  his  knees.  The  knee  trouble  has  become  so 
marked  that  he  can  not  work  because  of  the  uncertainty  of  his  gait. 
His  knees  gave  way  so  suddenly  several  times  that  he  was  precipitated 
to  the  ground  while  he  was  at  work.  He  sweats  easily.  He  has  slept 
poorly  for  several  weeks,  but  has  been  sleeping  better  during  the  last 
tw^o  weeks.  His  appetite  is  good,  and  he  has  lost  no  more  weight  than 
he  usually  does  during  the  summer,  about  10  pounds.  His  regular 
weight  is  165  pounds. 


224 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


L 


Fig.    112. — Section   of  toxic  thyroid. 


Fig. 


113. — The  ascini   are  widely   dilated  and  the   cells   form  papillary  projections   into   their 

lumen. 


DISEASES   OF    THE    THYROID    GLAND  225 

Examination. — The  man  presents  the  appearance  of  exhaustion  and 
appears  to  have  lost  much  weight.  When  his  statement  of  no  unusual 
loss  of  weight  is  questioned,  his  gaze  becomes  fixed  and  the  eyelids 
slowly  become  elevated  leaving  a  considerable  scleral  border  exposed. 
He  has  a  medium  goiter  on  the  right  side.  It  is  moderately  soft 
and  nonpulsating.  The  tremor  of  the  fingers  is  marked,  the  pulse  is 
120,  and  bounding,  the  apex  beat  is  broad  but  not  displaced.  The 
laboratory  findings  were  negative.     He  weighs  138. 

Diagnosis. — The  presence  of  toxic  goiter  is  unquestioned.  The  de- 
termination of  operability  is  the  only  question.  His  appetite  is 
good,  he  has  lost  considerable  weight  but  he  sleeps  well.  There  is 
nothing  in  the  urine  that  is  prohibitive. 

Treatment. — Eight  lobectomy  was  done. 

Pathology. — The  gross  specimen  showed  a  uniform,  reddish-gray, 
fine  granular  surface  (Fig.  112).  The  section  shoAved  a  typical  papil- 
lary proliferation  (Fig.  113). 

After-course. — He  improved  promptly  and  was  able  in  six  weeks 
to  do  heavy  work  which  he  continued  to  do  for  a  3'ear. 

Reentry. — Eighteen  months  later  he  felt  the  weakness  and  nerv- 
ousness returning.  Six  months  later  he  began  to  notice  palpitation 
of  the  heart  and  one  week  ago  his  knees  began  to  give  way 
again,  causing  him  to  fall.  He  has  lost  30  pounds  since  the  beginning 
of  his  trouble,  but  is  20  pounds  heavier  than  he  was  just  after  his 
first  operation.  He  still  sleeps  well,  the  appetite  is  fair,  and  the 
bowels  are  regular. 

Examination. — The  left  lobe  of  the  thyroid  is  enlarged,  smooth, 
fairly  firm,  movable.  There  is  noticeable  exophthalmos  and  Graefe 
is  positive.  He  is  of  a  nervous,  jerky  appearance.  Some  tremor  of 
the  tongue  and  fingers.    Pulse  90,  after  lying  in  bed  one-half  hour. 

Diagnosis. — The  diagnosis  was  easy,  as  in  the  first  entry. 

Treatment. — Two-thirds  of  the  remaining  lobe  was  removed. 

After-course. — Uneventful,  and  improvement  was  as  complete  as 
after  the  first  operation. 

Comment. — Here  one  lobe  enlarged  first  attended  by  the  typical 
symptoms.  Its  removal  cured  the  patient.  Obviously  the  left  lobe 
at  this  time  was  in  a  normal  state.  Later  it  developed.  This  is  often 
the  case.  When  one  gland  enlarges  rapidly,  usually  sooner  or  later 
the  opposite  side  will  enlarge.  The  patient  should  be  apprised  of  this 
possibility.    In  such  cases  it  is  important  to  remove  the  enlarged  lobe 


226  CLIXRAL    SrRGKRY    BY    CASE    HISTORIES 

before  its  fellow  begins  to  eubiroo.  It  is  interesting  to  note  that  tlie 
patient  had  lost  about  30  pounds  though  lie  was  not  aware  of  it.  It 
is  always  worth  while  to  learn  the  weight  of  the  patient  when  last 
weighed  and  then  by  comparing  the  present  weight  the  actual  loss 
can  be  approximated.  Patients  are  very  apt  to  be  much  mistaken  as 
to  the  actual  state  of  their  weight.  The  weakness  of  the  knees  prom- 
inent in  this  case  is  an  unusual  but  important  sign  of  hyperthyroid- 
ism. It  sometimes  appears  when  none  of  the  pathognomic  signs  are 
present  and  should  serve  to  cause  the  diagnostician  to  search  for 
other  symptoms. 

CASE  9. — A  housewife  aged  forty-three  came  to  the  hospital  with 
a  complaint  of  nervousness  and  weakness. 

Jlistorij. — Her  present  trouble  began  four  years  ago  with  nervous- 
ness and  increasing  rapidity  of  heart  action.  She  thought  they  were 
due  to  gallstone  trouble.  There  was  no  enlargement  of  the  neck  at 
this  time.  She  also  noticed  that  she  had  a  choking  cough  when  she 
drank  fluids.  This  cough  has  persisted  to  the  present  time.  Two 
years  ago  she  noticed  a  prominence  of  the  eyeballs  and  an  inability  to 
control  the  eyes.  The  nervousness,  palpitation,  and  eye  trouble  have 
steadily  grown  worse.  She  also  noticed  herself  getting  weaker  from 
the  beginning  of  her  trouble.  A  month  ago  she  had  an  attack  of 
some  kind  of  sore  throat  and  at  that  time  all  her  symptoms  grew 
suddenly  worse  and  have  continued  so.  She  has  been  troubled  with 
shortness  of  breath  and  puffiness  of  the  face  and  extremities  a  great 
deal  of  the  time.  She  also  noticed  these  symptoms  for  four  years,  but 
the  puffiness  of  the  extremities  has  not  been  so  bad  of  late.  Last 
winter  for  six  months  she  felt  well.  She  feels  hot  much  of  the  time, 
sweats  easily,  and  gets  flushed  when  excited.  She  has  to  have  a 
temperature  of  about  60°  F.  to  keep  comfortable.  Her  appetite  is 
very  good,  the  bowels  regular,  but  she  sleeps  poorly.  There  is  no 
urinary  disturbance. 

Examination. — Blood  pressure  205-95.  The  patient  is  a  well-nour- 
ished individual.  Her  general  appearance  is  that  of  an  anemic  per- 
son, but  the  mucous  membrane  of  the  eye  and  mouth  are  not  pale. 
She  does  not  appear  to  be  extremely  nervous,  but  she  has  a  marked 
tremor  of  the  fingers.  Both  lobes  of  the  thyroid  are  enlarged.  There 
is  a  moderate  exophthalmos,  otherwise  negative.  There  is  a  soft 
svstolic  murmur  over  the  base  of  the  heart.     This  is  not  transmitted. 


DISEASES    OF    THE    THYROID    GLAND 


227 


Diagnosis. — The  patient  bears  the  diagnosis  of  exophthalmic  goiter 
with  her.  The  fact  that  she  improved  once  spontaneously  and  now 
has  a  relapse  indicates  the  need  for  radical  procedure.  AVhile  the 
disease  is  well  marked  the  fact  that  she  has  lost  no  weight  and  has  a 
good  appetite  warrants  recourse  to  operation  without  preparatory 
treatment.    This  degree  of  toxicity  with  a  firm  uniformly  enlarged 


Fig.  114. — Section  of  glandular  thyroid. 


Fig.   115. — Slide  of  the  preceding  showing  increase   of  the  gland  acini. 


228  CLINICAL    SURGERY    BY    CASE    HISTORIES 

glaud  makes,  the  prognosis  somewhat  dubious  in  so  far  as  immediate 
results  are  concerned. 

Treatment. — The  right  lobe  of  the  thyi-oid  was  removed.  It  was 
small,  hard  and  densely  adherent  to  all  surrounding  structures.  It 
was  very  finnly  adhei-ent  to  the  trachea.  A  thin  slice  of  the  posterior 
and  internal  side  of  the  gland  was  cut  off  along  the  trachea.  Wound 
was  closed  without  drainage. 

PathoJogif. — The  section  of  the  gland  shows  the  tine  dotted  field 
of  a  glandular  proliferation  in  part  while  the  remainder  is  light 
gray  in  color  due  to  a  general  degeneration  of  all  elements  and  not 
to  a  colloid  increase.  The  slide  shows  a  great  increase  in  tlie  acini 
with  separation  of  the  cells  from  the  walls. 

After-course. — The  patient  made  a  normal  recovery.  For  the  first 
two  days  all  of  her  symptoms  Avere  aggravated,  but  after  this  they 
gradually  began  to  improve.  Her  highest  temperature  after  opera- 
tion was  100.5°  and  pulse  128.  She  was  extremely  nervous  the  first 
ten  days.  At  the  time  of  dismissal  from  the  hospital  her  pulse  was 
about  80  to  100  and  the  nervousness  was  much  improved.  She  con- 
tinued nervous  many  months,  but  gradually  improved,  although  her 
condition  after  several  years  is  still  unsatisfactory. 

Comment. — The  delay  in  improvement  may  have  been  due  in  part 
to  the  fact  that  she  evidently  had  an  acute  thyroiditis  some  months 
before  operation. 

CASE  10. — Young-  woman  aged  twenty-one  entered  the  hospital 
because  of  enlargement  of  neck,  nervousness,  rapid  heart,  and  diffi- 
culty in  swallowing. 

History. — She  first  noticed  an  enlargement  of  the  neck  at  the  age 
of  fourteen.  She  apparently  had  no  symptoms  from  it  and  conse- 
quently paid  little  attention  to  it.  Three  or  four  years  ago  she  no- 
ticed that  it  was  beginning  to  get  larger.  She  also  noticed  at  this 
time  that  she  was  getting  nervous.  Nervousness  was  the  only  symp- 
tom at  that  time.  This  steadily  increased.  The  next  thing  she  no- 
ticed was  a  rapid  heart  on  the  least  exertion,  which  would  slow  down 
when  she  rested.  She  has  noticed  during  the  last  two  years  that  the 
heart  was  more  rapid  even  during  rest.  Six  months  ago  her  family 
noticed  the  increasing  prominence  of  the  eyes  and  that  the  neck  en- 
largement was  increasing  more  rapidly  than  ever  before.  About  five 
weeks  ago  all  of  her  symptoms  increased  in  severity  rather  suddenly. 


DISEASES    OF    THE    THYROID    GLAND  229 

and  added  to  the  troubles  she  already  had,  a  difficult}^  in  swallowing 
fluids  set  in.  She  now  chokes  whenever  she  tries  to  swallow.  The 
palpitation  and  nervousness  is  much  more  severe.  She  has  hot 
flashes  and  feels  uncomfortably  warm  all  the  time.  Her  appetite  is 
good  and  her  bowels  regular.    She  sleeps  well. 

Her  menses  started  at  twelve  and  have  always  been  regular.  She 
flows  three  days  and  save  for  some  backache  she  is  free  from  pain. 
She  has  had  severe  attacks  of  tonsillitis  every  winter  as  long  as  she  can 
remember.  She  had  smallpox  three  years  ago  and  was  severely  sick. 
She  has  one  sister  and  five  brothers  who  are  well.  No  history  of 
goiter  in  the  family. 

Examination. — The  patient  thrusts  her  diagnosis  upon  the  observer. 
Eyes  moderate  but  positive  exophthalmos.  Von  Graefe,  Stellwag,  and 
Moebius  signs  are  all  positive.  Tonsils  hypertrophied,  filled  with 
large  crypts.     Tonsils  and  pharynx  red  and  look  inflamed. 

The  thyroid  gland  is  almost  uniformly  enlarged,  right  lobe  is  per- 
haps a  little  larger  than  the  left.  It  is  smooth,  rather  hard  and  non- 
pulsating.  Heart  not  enlarged,  apex  beat  is  in  the  5tli  interspace  and 
is  diffuse  and  bounding.  There  is  a  loud  blowing  murmur  at  the 
apex,  systolic  in  time,  and  is  well  transmitted  to  the  axilla  and  the 
left  side  of  the  sternum.  Pulse  rate  135,  regular,  the  blood  pressure 
156-75. 

The  reflexes  are  exaggerated.  The  patient  is  well  nourished,  rather 
slightly  built,  but  has  the  general  appearance  of  good  health.  She  is 
manifestly  extremely  nervous  and  has  a  marked  tremor  of  the  fin- 
gers.    The  skin  has  the  appearance  of  being  flushed. 

Diagnosis. — The  disease  is  labeled.  The  patient  not  so.  The  gland 
is  hard,  suggestive  of  thyroiditis.  The  heart  lesion,  judging  from  the 
location  and  transmission  of  the  murmurs,  is  probably  organic.  There 
has  been  a  slight  but  not  marked  loss  of  weight.  All  these  factors 
indicate  that  she  is  not  a  good  operative  risk. 

Preoperative  Management. — The  patient  was  put  to  bed  at  abso- 
lute rest  in  an  attempt  to  get  the  nervous  symptoms  ciuieted  down. 
She  refused  to  take  her  illness  seriously  and  sat  up  in  bed  whenever 
she  felt  like  it  and  did  about  as  she  pleased  generally.  Her  pulse 
rate  decreased  some  and  her  nervousness  was  some  better,  but  at  the 
end  of  a  week  she  returned  home  without  any  appreciable  improve- 
ment in  her  general  condition.     She  reentered  the  hospital  tAvo  weeks 


230 


CLIXICAL   SURGERY   BY    CASE    HISTORIES 


later,  her  condition  being  about  the  same  as  in  the  previous  entrance. 
The  pulse  was  146  after  being  in  bed  two  hours. 

Treatment. — Despairing  of  securing  a  better  state,  most  of  the  right 
lobe,  the  isthmus,  and  a  part  of  the  left  lobe  of  the  thyroid  were  re- 


Fig.   116. — Glandular  thyroid  with  a  small  encapsulated  area  in  the  center. 


Fig.    117. — Slide    of   the   preceding   showing   the   encapsulated   nodule   to   be    a   fetal    adenoma 
while  the  remainder  shows  papillary  proliferation  of  the  epithelium. 

moved.     The  whole  gland  was  large  and  very  vascular  and  rather 
difficult  to  remove  because  of  its  close  association  with  the  capsule. 

Pathology. — The  cut  surface  shows  a  fine  granular  field  with  an 
encapsulated  nodule  in  the  center  (Fig.  IIG).     The  slide  of  this  nod- 


DISEASES    OF    THE    THYROID    GLAND  231 

iile  shows  the  usual  structure  of  a  fetal  adenoma.  The  bulk  of  the 
gland  shows  a  good  deal  of  round  cell  infiltration  and  papillary  pro- 
liferation (Fig.  117). 

After-course. — On  the  day  of  the  operation  after  the  effect  of  the 
morphine,  given  before  the  operation,  had  worn  off,  there  began  to 
be  noticeable  an  increase  in  the  patient's  nervous  symptoms.  Her 
temperature  went  to  100.5°  and  the  pulse  to  140.  The  pulse  remained 
of  good  force  and  regular.  She  slept  very  little  that  night  even  after 
a  hypodermic  of  1/4  grain  of  morphine  was  given.  Her  temperature 
went  down  to  97.8°  during  the  night.  The  next  morning  all  symp- 
toms were  worse.  The  nervousness  increased  and  the  pulse  ran  be- 
tween 140  and  150.  She  vomited  frequently  a  green  fluid  during  the 
preceding  night  and  early  part  of  the  day.  The  respiration  went 
from  30  to  38.  By  noon  the  pulse  was  running  about  150  and  she 
developed  a  marked  arrhythmia.  It  was  weaker  at  the  wrist  than 
previously.  The  temperature  went  to  102.5,  axillary  as  it  could  not 
be  taken  accurately  by  mouth.  She  was  getting  a  sodium  bicarbonate 
solution  by  proctoclysis.  By  midnight  the  pulse  was  running  160  to 
165  stethoscope  count.  It  was  extremely  arrhji;hmic  and  could  not  be 
counted  accurately  at  the  wrist.  The  respiration  was  50  per  minute 
and  the  extreme  nervousness  gave  w^ay  to  periods  of  lethargy  at  times. 
She  had  the  appearance  of  being  extremely  toxic.  On  account  of  the 
extremely  rapid  and  irregular  pulse  rate  tr.  digitalis  ni  xv  had  been 
given  every  three  hours  by  mouth  since  noon.  Up  to  midnight  it  had 
apparently  had  no  effect.  An  ice  bag  was  placed  over  the  heart  be- 
cause the  patient  was  complaining  of  precordial  pain.  The  pain  ap- 
parently was  relieved  by  the  ice  bag,  but  it  had  no  effect  on  the  heart 
action.  Sodium  bicarbonate  had  been  given  all  day  by  mouth  and  by 
proctoclysis.  In  the  evening  and  up  to  midnight  the  patient  coughed 
at  times  and  brought  up  a  blood  stained  mucus.  Anteriorly  the  lungs 
showed  no  edema,  but  the  bases  were  not  examined  posteriorly  because 
it  was  deemed  best  not  to  disturb  the  patient  at  this  time. 

The  patient's  condition  improved  between  the  succeeding  midnight 
and  the  following  morning  very  noticeably.  The  restlessness  and 
nervousness  were  markedly  less.  The  patient  did  not  sink  into  the 
semistuporous  condition  as  she  did  at  intervals  the  day  before. 
The  respiration  rate  receded  to  42,  the  pulse  to  150  and  was  regular 
in  contrast  to  the  marked  arrhythmia  noticeable  during  the  preceding 
night.    The  cough  decreased  somewhat  and  the  sputum  came  up  with 


232  CLINICAL    SrRGERY    BY    CASE    HISTORIES 

greater  ease.  At  2  p.m.  there  was  no  particular  change  since  morning. 
Pulse  150,  regular,  strong,  respiration  40.  Temperature  dropped  from 
102.5°  to  100.5°  (axillary)  since  the  preceding  night.  General  con- 
dition of  the  patient  much  improved  the  next  day.  The  temperature 
in  the  morning  was  100.6"  and  the  pulse  130  and  strong.  The  nerv- 
ousness was  much  allayed  and  the  patient  seemed  much  imjiroved  in 
general. 

From  this  date  on  the  temperature  did  not  rise  over  99.5°  and  the 
patient's  general  condition  steadily  improved.  There  was  a  marked 
improvement  noticed  from  day  to  day  in  her  general  nervous  condi- 
tion. She  did  not  exhibit  the  jumpy  nervous  action  which  she  had 
previous  to  operation. 

Up  to  the  time  of  dismissal  her  pulse  did  not  go  below  110.  It 
remained  around  118  to  120  stethoscope  count.  The  systolic  murmur 
at  the  apex  persisted  up  to  the  date  of  dismissal  from  the  hospital. 
She  improved  rapidly  during  the  year  following,  and,  save  for  slight 
instability  of  the  nervous  system,  she  is  well. 

Conuuenf. — This  case  presents  a  stormy  recovery,  the  patient  ob\i- 
ously  just  missed  disaster.  It  is  clear  that  she  was  in  no  state  for 
radical  operation  and  ligation  would  liave  been  useless.  Preliminary 
treatment  of  a  month  or  two  in  bed  should  have  been  insisted  upon. 
Patients  shoAving  marked  toxic  symptoms  with  hard  glands  are  poorer 
risks  than  equally  toxic  ])atients  with  soft  pulsating  glands.  They 
do  not  show  the  prompt  improvement  after  operation.  If  improve- 
ment does  come  it  is  only  after  many  months.  If  one  is  asked  to 
choose  between  immediate  ojDeration  or  nothing  he  should  unhesitat- 
ingly choose  the  latter. 

CASE  11. — A  maiden  lady  aged  fifty  came  to  the  hospital  because 
of  weakness  and  palpitation. 

History. — For  the  past  six  months  the  patient  has  been  weak,  be- 
coming exhausted  on  the  least  exertion.  These  symptoms  date  from 
an  acute  tonsillitis  but  have  grown  progressively  worse.  Three  months 
ago  she  became  emotional  and  had  insomnia.  She  consulted  a  physi- 
cian who  discovered  a  goiter  and  noted  that  her  pulse  was  132.  For 
a  month  she  has  had  severe  headaches.  She  has  lost  30  pounds  in 
the  past  few  months.  For  the  past  few  weeks  she  has  had  choking 
spells,  particularly  after  first  getting  up  in  the  morning.  She  had  a 
goiter  as  a  child.    Ten  years  ago  she  had  a  spell  of  nervousness  similar 


DISEASES    OF    THE    THYROID    GLAND  233 

to  her  present  one  but  not  nearly  so  severe  and  it  subsided  in  a  few 
months  under  general  treatment.  She  had  typhoid  at  twenty  and 
diphtheria  at  twenty-two.    Her  father  and  one  sister  had  goiters. 

Examination. — The  patient's  general  attitude  is  apprehensive  and 
she  is  manifestly  nervous.  She  seems  depressed  and  her  skin  hangs 
loose  and  is  inelastic  as  though  she  had  lost  much  weight.  Her  gaze 
is  somewhat  fixed  and  staring,  but  there  are  no  definite  signs  present. 
She  has  a  medium  large,  fairl.y  firm,  nonpulsating  goiter.  The  right 
lobe  is  twice  the  size  of  the  left.  The  heart  rate  is  130,  the  apex 
bounding  but  not  displaced.  There  is  a  fine,  irregular  tremor  of  the 
hands.  The  reflexes  are  exaggerated.  The  urine  is  negative.  Blood 
pressure  180-95.    White  blood  count  7,400,  Poly.  51;  S.L.  28,  L.L.  21. 

Diagnosis. — The  condition  is  obviously  one  of  a  thyroid  intoxication 
which  evidently  is  still  progressing.  The  temperature  ranges  between 
97°  and  99.5°.  The  increasing  loss  in  weight,  and  the  addition  of  in- 
somnia to  the  other  nervous  symptoms  indicate  a  progressive  charac- 
ter. The  reduction  in  polynuclears  is  not  so  great  as  one  often  sees 
in  such  states,  yet  it  is  a  definite  reduction.  In  view  of  these  factors, 
the  patient  is  not  a  fit  subject  for  operative  treatment. 

Treatment. — The  patient  was  put  to  bed,  and  moderate  doses  of 
bromides  given. 

After-course. — The  pulse  reduced  to  110  and  there  was  some  gen- 
eral improvement.  At  the  end  of  two  weeks  she  became  mildly  de- 
lirious and  the  goiter  became  very  firm  and  sensitive  to  touch  and  in 
a  few  days  the  skin  over  the  right  lobe  became  somewhat  edematous. 
The  temperature  ran  from  97°  to  101°  and  the  pulse  and  other  symp- 
toms were  not  materially  changed.  She  remained  in  a  state  of  mild 
delirium  for  ten  weeks.  She  had  delusions  of  persecution  and  had 
to  be  constantly  watched  to  prevent  her  escaping.  She  complained 
to  her  relatives  of  the  treatment  accorded  her  by  the  hospital  at- 
tendants. She  was  examined  by  Dr.  Skoog  at  this  time.  The  follow- 
ing is  excerpted  from  his  report:  "Pupils  irregular  and  dilated.  Re- 
action to  light  and  accommodation  impaired.  Mild  temporal  pallor 
of  the  discs  and  mild  papillitis.  The  disc  borders  and  vessels  blurred. 
All  deep  reflexes  greatly  increased.  Babinski  and  Oppenheim  nega- 
tive. Superficial  reflexes  blunted."  At  the  tenth  week  the  delirium 
suddenly  disappeared.  She  volunteered  the  information  to  the  rela- 
tives that  her  statements  of  unkind  treatment  were  all  bosh  and  that 
she  was  at  a  loss  to  know  why  she  made  such  charges.    She  improved 


234 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


rapidly  aiul   was  allowed  to  go  home  in   three  more  weeks  with  a 
pulse  of  88,  temperature  98°  to  99.6°.    The  goiter    was  still  hard,  but 
not  so  sensitive  to  pressure.     She  was  advised  to  use  general  tonic 
measures  and  to  return  when  she  had  regained  her  weight. 
■Reentry. — Five  months  after  dismissal  she  returned  having  gained 


*'^ia:^;g/g^^ 


Fig.    118. — Gross   appearance    of    nonsuppurating   thyroiditis. 


Fig.   119. — The  slide  shows  acini  filled  with  colloid  much  retracted  from   the  walls  and  show- 
ing vacuoles  in  the  substance. 


DISEASES    OF    THE    THYROID    GLAND  235 

40  pounds  in  weight.  Her  appetite  was  good.  The  goiter  was  much 
softened  but  nonpulsating,  tremor  was  marked  and  pulse  110.  The 
right  lobe  of  the  thyroid  and  the  isthmus  were  removed.  There  was 
moderate  but  not  excessive  difficulty  in  separating  it  from  its  cap- 
sule. Postoperative  recovery  was  uneventful.  The  section  of  the 
gland  was  unusually  pale  and  uniformly  granular  (Fig.  118).  Kound 
cells  were  numerous  and  about  the  periphery  polynuclears  were  in 
evidence  in  small  numbers  (Fig.  119). 

Comment.— The  hardness  and  sensitiveness  of  this  goiter  suggested 
an  infection,  but  the  leucocytes  never  reached  10,000  and  the  poly- 
nuclears remained  low,  both  factors  against  suppuration.  The  phys- 
ical signs,  however,  warranted  one  as  regarding  the  organ  as  being 
in  a  state  of  reaction,  therefore,  a  nonsuppurative  thyroiditis.  The 
long  period  of  delirium  and  the  type  of  mental  disturbance  was  un- 
usual. Operation  at  the  height  of  the  disease  would  no  doubt  have 
resulted  fatally. 

CASE  12.— A  widow  aged  fifty-seven  came  because  of  dyspnea 
and  nervousness. 

History.— The  patient  is  short  of  breath  on  exertion.  She  first  no- 
ticed this  a  year  ago,  but  recently  it  has  become  so  aggravated  that  her 
activities  have  had  to  be  considerably  limited.  The  shortness  of 
breath  is  most  distressing  when  she  attempts  to  lie  down,  so  that  she 
is  obliged  to  sleep  propped  on  many  pillows.  She  has  been  exceed- 
ingly nervous  and  irritable  during  the  past  six  months.  She  has  had 
a  goiter  for  thirty  years,  but  it  has  never  caused  her  any  trouble. 
Recently  she  has  felt  that  it  might  be  adding  something  to  her 
dyspnea.  Her  general  health  during  her  childbearing  period  w^as 
good.     She  had  three  children. 

Examination. — The  patient  looks  ill  and  distressed  and  appears  as 
though  she  might  have  lost  weight  recently.  She  has  a  moderately 
large  bilateral  goiter.  The  carotids  pulsate  markedly,  but  the  gland 
does  not  seem  to  participate.  The  goiter  is  firm,  somewhat  bosselated. 
The  apex  of  the  heart  is  in  the  axillary  line  and  is  diffuse.  The  rate  is 
96  and  it  intermits.  The  right  border  is  in  the  midsternal  line.  There 
are  no  murmurs.  There  is  a  marked  tremor  of  the  hands.  Bp.  210-120. 
Urine  1.012,  negative. 

Diagnosis. — The  goiter  is  firm  as  though  long  stationary.  It  does 
not  seem  to  displace  or  compress  the  trachea  but  because  of  its  size 


236  CLINICAL    ST^RGERY    BY    CASK    HISTORIES 

and  density  may  readily  do  so  wlien  slie  lies  down.  The  enlarged 
heart  is  that  of  a  degenerated  myoeardiuni  rather  than  that  of  thyroid 
intoxication.  The  degeneration  likely  is  due  to  the  long  existence  of 
the  goiter.  The  pnlse  rate  is  that  of  decompensation  rather  than  that 
of  hyperthyroidism,  since  it  becomes  more  rapid  on  exertion  and  is 
slowei"  in  the  morning.  The  nervonsness  seems  more  that  of  arro- 
gance than  of  thyrointoxication.  The  tremor  seems  to  be  that  of 
hyperthyroidism  and  the  loss  of  weight  is  likewise  suggestive  of 
intoxication. 

Treatment. — It  was  decided  to  call  the  therapeutic  test  to  our  aid. 
Rest  in  bed  with  cardiac  stimulants  improved  the  dyspnea  under  cer- 
tain conditions  and  the  edema  disappeared.  The  nervousness  and 
tremor  were  not  lessened,  they  were,  on  the  contrary,  rather  worse 
than  at  the  beginning  of  the  treatment.  After  using  heart  stimu- 
lants tliree  weeks,  a  right  lobectomy  was  done.  A  well  localized  ade- 
noma lay  behind  the  trachea  at  the  level  of  the  suprasternal  notch 
(Fig.  120).  The  technic  was  made  more  difficult  because  the  patient 
insisted  that  the  attempts  to  raise  the  chin  caused  an  intolerable 
shortness  of  breath. 

Pafhologi/. — The  adenoid  ])ortion  had  undergone  a  general  degen- 
eration, evidently  a  necrobiosis.  The  remainder  of  the  lobe  showed 
some  prolifei'ation  indicating  that  there  is  a  mild  thyroid  activity. 
The  slide  shows  a  low  epithelium  Avith  moderate  increase  in  colloid 
which  is  acidophilic    (Fig.  121). 

Afler-course. — Some  hours  after  the  operation  the  patient  com- 
plained of  the  old  shortness  of  lireath.  The  patient  showed  a  mild 
cyanosis  and  an  obstruction  to  both  ins]nration  and  expiration  more 
mai'ked  than  before  operation.  ]t  was  tliought  that  hemorrhage  had 
taken  place  into  the  space  where  the  lobe  lay  and  was  compressing 
the  trachea.  The  wound  was  opened  and  a  clot  of  blood  as  large  as 
tlie  tliyroid  was  removed.  A  drain  was  placed  in  this  pocket  after 
the  clot  was  removed.  Convalescence  after  this  was  uneventful.  The 
dyspnea  largely  disajipearcd  and  the  heart  rate  lessened  albeit  with 
cai'diac  tonics.  The  nervous  sym])toms  did  not  improve  following 
the  operation.  On  the  contrary,  after  three  months  they  increased, 
but  it  was  never  determined  whether  there  was  an  actual  mental  ab- 
erration or  just  the  latent  manifestation  of  a  strenuous  disposition. 
She  died  six  months  later  from  general  dro]isy,  due  to  an  active  re- 
turn of  the  cardiac  decompensation  dependent  on  ill-advised  activity. 


DISEASES    OF    THE    THYROID   GLAND 


237 


Comment. — The  thyroid,  aside  from  the  obstruction,  had  little  to 
do  with  the  picture  as  detailed.  Very  possibly  the  long  existing  goi- 
ter had  much  to  do  with  the  cardiac  muscular  system.  The  high 
blood  pressure  may  be  sufficient  explanation  for  the  difficulty  with 
the  heart.     It  seems  to  me  the  state  of  the  thvroid  was  largely  re- 


i 

^^^^v 

'0-^ 

'"#N^ 

^ij^m.  - 

Hiitt%h              H 

% 

BHHmJ^^v  ^      ^1^1 

^^m 

w%  -■ 

^'^^^"^ 

-w-    .. 

Fig.    120. — Gross    appearance    of    the    thyroid    showing    round    nodule    which    lay    behind    the 

trachea. 


y    >    .^^/V^.i"  '."  .  \1  /  .^  -.'•'     -f..:       '..•       Js^.   \ 


Fig.    121. — Adenoma   with   palely   staining   cell   and   degenerated   colloid. 


238  CLINICAL    SURGERY    BY    CASE    HISTORIES 

sponsible,  feu-  the  dyspnea,  particularly  when  the  patient  held  her 
head  aloft.  The  operation  despite  this  was  ill-advised.  The  patient 
expected  complete  relief  from  all  her  symptoms  and  failing  to  attain 
this  visited  invective  on  her  regular  medical  attendant.  AVhcn  lobes 
extend  behind  the  trachea  adequate  drainage  should  be  practiced. 

CASE  13. — I  was  called  to  see  a  married  woman  of  twenty-six 
years,  because  of  extreme  nervousness  and  vomiting. 

History. — The  patient  was  delicate  as  a  child.  She  had  chorea  at 
nine.  Since  then  she  has  been  very  nervous.  She  was  married  tAvo 
years  ago  and  has  one  child  eight  months  old.  She  was  very  weak 
during  pregnancy  and  spent  much  of  her  time  in  bed.  Three  months 
ago  she  again  became  pregnant.  She  vomited  a  good  deal  and  became 
very  weak.  Because  of  this  she  was  curetted  a  month  ago.  She  has 
been  worse  since.  She  has  continued  to  vomit,  and  emaciation  has 
been  progressive  and  rapid.  She  is  extremely  nervous  and  sweats 
easily  and  is  sleepless  unless  given  anodynes. 

Examination. — The  patient  is  extremely  emaciated  and  is  exceed- 
ingly nervous.  The  least  attempt  at  examination  aggravates  the 
general  nervous  attitude.  There  is  marked  exophthalmos,  Kocher 
and  Dalrymple  signs  are  well  marked.  There  is  extreme  tremor. 
There  is  a  medium  symmetrical  goiter  which  pulsates  violently.  The 
apex  is  in  the  midclavicular  line,  is  diffuse  and  pounding.  The  rate 
is  110-130,  irregular  in  rate  and  volume.  The  temperature  varied 
between  99°  and  102.5°,  the  respiration  between  28  and  36.  The  pa- 
tient's father,  a  physician,  declares  he  had  not  noticed  either  goiter 
or  eye  signs  until  five  or  six  days  ago  and  the  attending  physician 
had  not  yet  noted  their  presence,  the  father  having  suppressed  his 
fears. 

Diagnosis. — The  cause  of  the  nervous  state  Avas  easy  to  perceive  at 
the  time  of  my  visit.  A  marked  acute  thyrointoxication  in  a  woman 
under  par,  developing  during  an  early  pregnancy  and  curettment, 
presents  a  problem  in  the  diagnosis  as  to  the  operative  resistance. 
Since  ths  gland  was  pulsating  and  the  patient  obviously  was  rap- 
idly growing  worse,  it  was  deemed  warranted  to  recommend  opera- 
tion, though  it  was  emphatically  impressed  that  to  do  so  or  not  to  do 
so  were  both  invested  with  great  danger. 

Treatment. — The  proposal  to  ligate  the  right  superior  thyroid  ves- 


DISEASES    OF    THE    THYROID    GLAND  239 

sel  was  rejected.     She  was  placed  on  bromides  and  morphine  in  the 
hope  of  lessening  the  extreme  nervous  state. 

After-course. — The  patient  passed  from  nervousness  to  delirium 
and  after  the  beginning  of  the  delirium  the  temperature  ranged 
higher  and  she  died  in  two  weeks. 

Comment. — To  have  operated  Avould  have  been  foolhardy.  This 
patient  was  observed  years  ago,  during  the  period  I  believed  what  I 
read  on  this  subject.  In  these  eases  nothing  avails.  One  scarcely 
knows  what  to  do,  and  when  in  that  state  of  mind  the  obvious  thing 
to  do  is  nothing. 

Some  of  these  extreme  toxic  cases  improve  after  abortion,  and  I 
agreed  with  the  attending  physician  that  he  acted  wisely.  In  this 
case,  however,  there  was  no  thought  of  the  possibility  of  thyrointox- 
ication  at  the  time  the  uterus  was  emptied.  The  character  of  the 
nervousness  was  such  that  a  possible  thyrotoxic  origin  should  have 
suggested  itself.  Emesis  gravidorum  in  the  absence  of  thyrotoxic 
symptoms  does  not  have  the  same  type  of  nervousness,  but  the  bor- 
derline is  close  enough  to  cause  one  to  wonder  whether  the  endocrine 
system  may  not  play  a  part  in  every  ease  of  excessive  vomiting  of 
pregnancy. 

CASE  14. — I  was  called  to  see  a  matron  of  forty-nine  because  of 
palpitation  and  loss  of  weight. 

History. — The  patient  began  to  be  nervous  at  times  more  than  a 
year  ago.  She  attributed  this  to  the  approaching  menopause.  She 
began  to  notice  some  swelling  in  the  feet  nine  months  ago.  She  had 
palpitation  and  some  pain  in  the  region  of  the  heart.  She  was 
treated  by  a  rest  in  bed  for  a  time  and  the  swelling  of  the  feet  dis- 
appeared. She  had  a  goiter  at  this  time  the  size  of  a  lemon.  This  was 
not  regarded  as  a  matter  of  consequence  by  her  attendant  because  she 
had  a  goiter  when  a  girl  which  disappeared  after  a  time.  Tv/o 
months  ago  she  became  worse  and  sanitarium  treatment  was  again 
advised  and  continued  for  six  weeks.  She  was  given  enemas  by  her 
attendant.  She  improved  under  this  treatment.  The  diagnosis  was 
cancer  of  the  stomach.  She  returned  home  two  weeks  ago  and  became 
worse  again.  Since  that  time  she  has  been  vomiting  persistently  at 
intervals.  AVhen  these  spells  are  on  she  is  unable  to  retain  anything 
whatever.  The  goiter  has  disappeared.  She  used  to  weigh  150 
pounds,  but  has  lost  gradually  since  the  beginning  of  her  sickness. 


240  CLIXTCAL   SURGERY    BY    CASE    HISTORIES 

She  has  seven  chihlrcn,  no  niiscai-riages  and  never  any  pelvic  trou- 
ble. Her  periods  were  nuieh  delayed  several  times  during-  the  past 
two  years.  The  chart  shows  a  pulse  rate  varying  from  120  to  144, 
the  temperature  99.2°  to  101.6°  and  the  respiration  26  to  44.  The 
pulse  on  several  occasions  is  recorded  as  being  70.  The  nurse  states 
that  she  is  of  the  opinion  that  every  other  beat  was  too  faint  to  be 
counted  certainly.    She  counted  only  what  she  w^as  sure  she  could  feel. 

Examination. — The  patient  is  much  emaciated,  stares  anxiously 
straight  ahead  and  a  movement  of  the  liand  precipitates  a  rapid  fine 
tremor.  The  left  foot  pits  slightly  on  pressure.  The  abdomen  is 
flat  and  painless  to  pressure.  The  aorta  pulsates  visil)ly.  The  apex 
is  in  the  midclavicular  line,  diffuse  and  bounding.  Tlie  right  heart 
reaches  to  near  the  midsternal  line.  There  are  no  adventitious 
sounds,  but  occasionally  tlu^  ventricle  fails  to  contract.  There  is  a 
palpable  enlargement  of  the  right  lobe  of  the  thyroid  and  there  is  a 
definite  Moebius  in  the  left  eye  and  voluntary  winking  occurs  only 
at  unusually  long  intervals.  The  lungs  are  negative,  the  pulse  140, 
temperature  101.6^,  respiration  26-34.  The  carotids  pulsate  vio- 
lently.   The  patient  weighs  not  more  than  70  pounds. 

Diagnosis. — The  preceding  nervousness,  swelling  of  the  feet  and 
emaciation  suggest  a  nutritional  disturbance.  The  fact  that  until  re- 
cently she  has  been  able  to  eat  normality  indicates  an  increased  de- 
struction rather  than  a  failure  to  absorb  nutriment.  The  fever  and 
rapid  heart  are  not  compatible  with  the  theory  of  a  digestive  dis- 
order. The  nervousness  and  the  character  of  the  heart  beat  suggest  a 
disturbance  of  the  nervous  system.  The  fact  that  she  had  a  notice- 
able goiter  and  still  retains  fairly  well  marked  eye  signs  makes  it 
likely  that  the  thyroid  is  the  source  of  intoxication.  The  extreme 
emaciation  and  finally  the  vomiting  are  in  no  wise  incompatible  with 
this  theory. 

Treatment. — The  patient  was  given  morphine  to  suppress  the  per- 
sistent vomiting. 

After-course. — The  patient  died  in  two  days  with  increasing  ra- 
pidity of  the  heart  and  persistent  vomiting. 

Comment. — The  significant  facts  here  presented  are  the  nervous- 
ness followed  l)y  a  goiter  that  appeared  quickly,  remained  for  a  time, 
and  vanished.  Goiters  that  appear  suddenly  and  as  suddenly  dis- 
appear are  sometimes  wandering  goiters,  being  intrathoracic  when 
not  in  evidence  in  the  neck.     When  toxic  goiters  begin  gradually  to 


DISEASES    OF    THE    THYROID    GLAND  241 

become  reduc-ecl  in  size  without  the  lessening  of  the  symptoms,  one 
may  be  sure  that  disaster  is  impending.  These  belong  to  the  most 
toxic  of  all  conditions,  and  death  nearly  always  follows. 

CASE  15.— A  farmer's  wife  aged  thirty -five  came  to  the  hospital 
because  of  heart  trouble. 

History. — The  patient  has  had  seven  children,  the  youngest  of 
which  is  three  years  old.  She  had  an  abortion  at  three  months,  four 
months  ago.  She  has  had  a  goiter  six  years  and  the  eyes  became 
prominent  a  year  later.  Still  a  year  later  she  became  short  of  breath 
and  had  palpitation.  All  her  symptoms  are  worse  since  the  abortion. 
She  menstruates  regularly  four  days  without  pain.  Her  symptoms 
are  not  worse  at  these  times. 

Examination. — The  thyroid  is  moderately  enlarged,  particularly 
the  right  lobe.  It  pulsates  markec%,  and  the  superior  thyroid  arteries 
are  easily  palpable.  The  eyes  are  prominent  and  show  Graefe  and 
Dalrymple  signs.  The  heart  extends  beyond  the  mid-clavicular  line 
and  the  apex  beat  is  diffuse.  The  uterus  is  in  position  but  is  large  and 
sensitive  to  bimanual  examination.  The  ceiMx  is  deeply  lacerated 
and  extensively  eroded  and  is  covered  by  a  diffuse  discharge.  The 
right  ovary  is  as  large  as  a  hen's  egg  and  lies  low  in  the  culdesac. 
The  perineum  shows  second  degree  laceration.  Pulse  140,  full  and 
ciuiek. 

Diagnosis. — The  fact  that  the  patient  has  been  markedly  vforse 
since  the  abortion  four  months  ago,  made  it  appear  that  a  correction 
of  the  pelvic  lesion  would  result  in  an  amelioration  of  the  thyroid 
symptoms. 

Treatment. — An  enlarged  ovary  was  removed  and  the  cervix  ampu- 
tated and  the  perineum  repaired. 

PatJwlogij. — The  ovary  was  made  up  of  many  follicular  cysts  and 
the  capsule  was  thickened.     The  cer\nx  contained  many  small  cysts. 

After-course. — The  appetite  and  sleep  and  the  general  sense  of 
well  being  improved  much.  The  heart  did  not  slow  materially,  nei- 
ther did  the  pulsation  in  the  thyroid  markedly  lessen.  Edema  of  the 
feet  developed  after  six  months,  and  the  patient  gradually  failed 
under  the  sign  of  myocardial  weakness. 

Comment. — This  patient  should  have  had  a  preliminary  ligation  of 
the  thyroid  vessels  followed  in  a  few  months  by  a  repair  of  the  pelvic 
lesions   and   still  later   by   a   lobectomy;    however   it   seems   evident 


'242  CMXICAL    SIKOKRY    BY    CASE    HISTORIES 

that   tlierc   was   a    iii\-()cai-tlial    degeneration   before   she   came   under 
observation. 

CASE  16. — A  restaurant  proprietor  came  to  the  hospital  bacauss 
of  palpitation  and  nervousness. 

Hisiortf. —  The  patient  lias  always  liad  <iood  health  until  the  pres- 
ent illness.  About  five  weeks  ago  without  known  cause  he  began  to 
feel  worn  out  and  was  irritable.  Following  this,  palpitation  began. 
This  rai)idly  increased  so  that  he  was  obliged  to  go  to  bed.  He  had 
some  fever.  He  has  been  in  bed  two  weeks.  His  sleep  is  fair  and 
there  is  no  shortness  of  breath.  The  palpitation  is  made  Avorse  by 
excitement  rather  than  by  exercise.  He  has  one  child,  a  daughtei'. 
who  has  been  operated  on  for  exophthalmic  goiter. 

Examination. — The  temperature  is  100^,  the  pulse  106,  and  the 
respiration  30.  Lungs  negative ;  abdomen  negative.  The  apex  beat 
is  diffuse,  a  fingerbreadth  outside  the  nipi)le  line.  The  right  border 
is  near  the  center  of  the  sternum.  The  patient  was  apprehensive  but 
otherwise  all  was  negative.  Mitral  sounds  not  clear  but  no  distinct 
murmin-s.  The  laboratory  examinations  were  without  moment.  There 
Avas  marked  tremor. 

Diagnosis. — The  slightly  dilated  heart  and  the  indistinct  character 
of  the  mitral  sounds,  the  rapid  pulse,  the  slight  but  persistent  fever 
made  an  endocarditis  the  most  probable  diagnosis,  though  there  were 
no  laboratory  findings  to  support  this  conclusion. 

Treatment. — The  patit>nt  was  put  to  bed  and  sedatives  were  admin- 
istered. 

After-course. — With  rest  in  bed  the  temperature  varied  from  97.6"^ 
in  the  morning  to  100°  at  five  in  the  afternoon.  The  pulse  from  80 
to  100.  and  the  respirations  from  IS  to  22.  This  was  continued  for 
about  five  weeks.  He  returned  homo  without  noticeable  improve- 
ment and  returned  in  two  months  in  tiie  same  condition.  As  I  was 
sitting  beside  him,  trying  to  figure  out  the  cause  of  the  trouble,  he 
asked  me  point  blank  what  the  nature  of  his  trouble  was.  I  started 
to  explain  to  him  that  the  cause  v.-as  indeterminate,  but  that  the 
heart  Avas  probably  the  organ  at  fault.  I  noticed  his  fixed  gaze  which 
caused  me  to  pause,  gradually  the  upper  lid  retracted  revealing  an 
arc  of  sclera  between  it  and  the  iris  (Kocher's  sigii).  This  witli  the 
fixed  gaze  (Stellwag's  sign)  established  the  diagnosis  of  hypertliy- 
roidism.  Therefore,  instead  of  expounding  on  endocarditis  I  ex- 
plained the  rolatitin  lietween  hyperthyroidism  and  the  lieait's  action. 


DISEASES    OF    THE    THYROID    GLAND  243 

There  was  no  enlargement  of  the  thyroid.  He  was  placed  on  seda- 
tives, but  there  was  no  improyement.  On  the  contrary,  the  nervous- 
ness and  sleeplessness  increased.  At  the  end  of  a  month  the  right 
lobe  of  the  thyroid  began  to  enlarge  and  attained  the  size  of  a  hen's 
egg.  The  left  lobe  did  not  emnlate  its  fellow.  While  the  symptoms 
w^ere  at  the  height,  the  gland  began  to  regress  and  within  a  few 
months  entirely  disappeared,  while  the  nervousness  and  sleeplessness 
increased.  There  was  mental  confusion  at  times.  After  several 
months  of  further  treatment  he  improved  and  returned  to  his  home. 
Soon  nervousness  increased  and  the  heart  rate  increased.  He  died 
with  ascending  temperature  and  a  countless  pulse. 

Comment. — The  rapid  heart  and  peculiar  nervousness  with  tremor 
should  have  been  sufficient  to  make  the  diagnosis  at  the  time  of  his 
first  admission  to  the  hospital.  The  wide  apex  beat  without  evidence 
of  definite  cardiac  lesion  was  confirmatory.  This  case  is  particularly 
interesting  because  the  thyroid  enlarged  then  regressed  without  there 
being  any  change  in  the  general  symptoms. 

CASE  17. — A  widow  of  fifty-eight  came  because  of  a  goiter. 

History. — -AVhen  she  was  nine  years  old  it  was  noticed  that  she  had 
an  enlargement  of  the  neck.  It  grew  rapidly  for  a  time  but  improved 
under  the  external  use  of  iodine.  It  remained  stationary  then  until 
she  became  pregnant,  when  it  enlarged  rapidly  again.  After  deliv- 
ery it  subsided.  This  sequence  repeated  itself  with  every  pregnancy. 
After  she  ceased  to  bear  children  it  remained  stationary  until  a  year 
ago.  Nine  months  ago  she  had  influenza  and  she  has  not  fully  recov- 
ered. From  that  time  she  has  been  nervous  and  trembles  under 
exertion  or  excitement.  A  month  after  she  had  influenza  she  had  a 
spell  with  her  heart.  She  had  violent  palpitation,  became  weak,  and 
short  of  breath.  Since  then  she  has  become  more  nervous.  She  was 
in  bed  six  weeks  and  improved  somewhat.  She  has  been  up  a  part  of 
the  day  the  past  several  months.  She  sleeps  poorly  and  the  appetite 
is  variable.    She  has  lost  60  pounds  in  weight. 

Examinntion. — There  are  no  eye  signs.  She  has  a  large,  hard,  nod- 
ular goiter.  It  is  freely  movable  and  not  sensitive.  The  apex  is  in 
the  anterior  axillary  line  and  is  very  diffuse  and  bounding.  There  is 
no  enlargement  to  the  right.  Pulse  140,  arrhythmic.  No  murmurs. 
There  is  a  fine  tremor  of  the  hands.  The  urine  contains  a  trace  of 
albumin.     Hg.  70,  AV.b.c.  6,800,  Poly.  35,  L.L.  13,  S.L.  49,  Eos.  3. 


244 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


After  being  in  bed  a  week  the  pulse  beat  varied  between  100-110  with 
oecasional  exacerbations  to  140.    At  times  it  became  as  low  as  72. 

Diagnosis. — The  patient  has  a  goiter  and  a  bad  heart.  The  problem 
is  to  determine  the  relation  of  the  two  and  from  this  to  determine  the 
plan  of  treatment.     That  the  tronlile  should  date  from  the  influenza 


i*^SJ^; 


Fig.  122. — Section   of  a  degenerated  toxic  goiter. 

helps  but  little,  for  the  cardiac  trouble  might  have  been  excited  by 
this,  and  many  previouslj'  quiescent  goiters  have  taken  on  vicious  se- 
cretion after  attacks  of  influenza.  Despite  the  dilated  heart,  there 
are  no  edemas  and  there  is  no  evidence  that  dyspnea  followed  exer- 
tion. That  the  cardiac  trouble  is  primary  does  not  seem  likely.  On 
the  other  hand,  she  has  lost  60  pounds  which  harmonizes  with  thyroid 
intoxication  but  not  with  a  primary  cardiopathy.     The  high  lympho- 


DISEASES    OF    THE    THYROID    GLAXD 


245 


cyte  count  speaks  distinctly  for  thyroid  disease,  as  does  the  tremor. 
Xo  change  in  the  gland  appeared  Avhieh  could  be  connted  in  favor  of 
such  a  diagnosis  neither  conld  any  be  expected,  for  these  old  veterans 
do  not  enlarge  even  if  hypersecretion  takes  place.  It  seems  fair  to 
assume  that  she  has  a  thvroid  intoxication  and  as  a  result  a  disturbed 


V^ 


A- 


1 


'U>^\ 


<      ir  r 


Fig.  12i 


-Slide  of  a  degenerated  toxic  goiter. 


heart.  This  conclusion  is  in  harmony  vith  her  attitude,  for  after  be- 
ing in  bed  two  weeks  she  did  not  improve  and  refused  to  stay  in  bed 
longer.  Cardiac  patients  when  they  are  once  '"bed  broke"  are  con- 
tented to  remain,  at  least  they  do  not  exhibit  the  wild  determination 
to  get  up  that  thj-rotoxic  patients  do. 

Treatment. — The  left  lobe  and  a  portion  of  the  right  were  removed. 
The  tumor  was  large,  extending  deeply  behind  the  clavicle.  It  was 
firmly  adherent  to  the  capstde. 


246  CLINICAL    SCRGERY    BY    CASK    HISTORIES 

Pathology. — Many  calcified  areas  were  scattered  throughout  the 
gland.  The  main  portion  showed  a  grayish  white  translucent  appear- 
ance, with  here  and  there  a  cyst  (Fig.  122).  In  some  areas  the  slides 
show  some  round-celled  infiltration,  bnt  for  the  most  part  the  acini 
are  large  and  lined  with  flat  cells  from  which  the  colloid  content  has 
retracted.  The  colloid  masses  show  openings  which  make  the  whole 
area  resemble  an  aeroplane  view  of  a  shell-riddled  battlefield  rather 
than  the  usual  vacuoles  seen  in  this  situation  (Fig.  123). 

After-course. — In  the  first  few  hours  following  the  operation  the 
temperature  rose  to  100^'  and  the  pulse  to  130.  but  it  was  regular  and 
of  good  volume.  The  patient  was  nervous  and  restless.  The  follow- 
ing morning  the  pulse  was  145  and  markedly  arrhythmic  but  the  vol- 
ume remained  good.  She  was  markedly  more  nervous  and  restless. 
By  evening  the  pulse  was  150  and  softer.  The  temperature  rose  to 
104  at  midnight  when  she  died.  Sodium  bicarbonate  and  heart  tonics 
had  been  given. 

Comment. — Obviously  the  ])atient  should  not  have  been  operated 
on.  The  marked  loss  of  weight  and  the  high  lymphocyte  count  should 
have  been  warning  enough.  A  goiter  which  is  not  toxic  admits  of 
operation  under  local  anesthesia  no  matter  what  the  heart  condition. 
The  weakened  heart  muscles  do  not  bear  the  strain  of  superintoxica- 
tion. 

CASE  18. — A  single  w^oman  of  twenty-two  came  to  the  hospital  be- 
cause of  an  enlargement  of  the  neck  and  prominent  eyes. 

History. — Her  father  died  of  cancer  of  the  stomaeh,  and  one  sister 
died  of  tuberculosis.  As  a  girl  she  was  strong  and  healthy.  Her 
menses  were  regular  until  a  year  ago  when  they  ceased  without  known 
cause.  Six  months  ago  she  consulted  her  family  physician  who  found 
a  pulse  of  100  with  a  temperature  of  98°.  She  was  nervous  but  well 
nourished  and  had  lost  no  weight.  Two  weeks  later  the  pulse  was 
120,  irregular  and  the  apex  beat  was  diffuse  and  she  was  more  nerv- 
ous. The  pulse  remained  so  for  six  weeks  when  it  became  130.  At 
this  time  the  urine  was  1012  without  foreign  elements.  The  blood 
pressure  was  150.  At  this  time,  too,  three  months  ago,  eye  signs  were 
first  noticed.  Tremor  likewise  was  pronounced  for  the  first  time.  The 
month  following  the  eye  signs  became  more  prominent  and  the  pulse 
increased  to  144;  some  thyroid  enlargement  was  noted  for  the  first 
time.     During  the  three  weeks  following-,  the  thvroid  increased  con- 


DISEASES   OF    THE    THYROID    GLAND 


247 


.#  .. 


'r-i- ..: 

%-l 

ml  c 

W^^^^^mJ^ 

Fig.    \24-A.  —  I'niiillary    formation    in   exoiilitlialinic   goiU 


%'Lw 


Fig.    124-B. — Cell   degeneration   and    exfoliation   in   exophthalmic   goiter. 


248  CLINICAL   SURGERY    BY    CASE    HISTORIES 

siderably  in  size.  Vomiting  appeared  for  the  first  time.  She  could 
not  remain  in  bed  as  ordered  because  she  was  ' '  too  nervous. ' '  During 
the  two  weeks  preceding  the  entrance  into  the  hospital  she  lost  rapidly 
in  weight. 

Examination. — The  i)atient  is  highly  nervous  and  regards  the  ap- 
proach of  the  examiner  with  apprehension.  The  eyes  are  obviously 
protuberant.  Stellwag's  sign  is  well  marked,  the  intervals  between 
involuntary  winking  being  the  longest  I  have  ever  seen.  When  the 
gaze  was  fixed  on  the  examiner's  finger,  the  lids,  notably  the  right, 
retracted  fully  an  eighth  of  an  inch  above  the  corneal  border 
(Kocher's  sign).  In  repose  there  was  a  ring  of  white  about  the  cor- 
nea (Dalrymple's  sign),  giving  a  permanent  look  of  terror.  There 
was  marked  tremor  of  the  hands.  There  was  a  moderate-sized  bilat- 
eral goiter,  of  medium  consistence  without  pulsations.  The  apex  beat 
was  wide,  the  impulse  pounding.  The  pulse  was  120,  respiration  28, 
temperature  98°.  During  her  first  few  days'  stay  in  the  hospital  it 
remained  about  the  same. 

Diagnosis. — The  name  of  the  disease  was  determinable  at  a  glance. 
The  diagnosis  of  the  actual  state  of  the  patient  was  the  only  prob- 
lem. The  rapid  development  of  the  disease  and  the  progressive  char- 
acter stamped  it  as  one  of  great  gravity.  The  loss  of  weight,  the  lack 
of  appetite  and  the  recurrent  vomiting  all  attested  to  its  progressive 
character.  The  exact  amount  of  weight  lost  was  not  exactly  deter- 
minable, but  was  estimated  about  30  ])ounds.  Because  of  the  evi- 
dent progressive  character,  it  was  determined  to  interfere. 

Treatment. — She  was  j)laced  on  sodium  bromide  gr.  xx  three  times 
a  day  for  the  four  days  she  remained  in  the  hospital  before  opera- 
tion. This  did  not  produce  any  perceptible  lessening  of  the  nervous 
manifestations.  The  right  lobe  and  the  isthmus  were  removed  on  the 
fifth  day.     The  operation  presented  no  peculiar  difficulties. 

Pathology. — The  cut  surface  of  the  gland  was  a  deep  wine  color 
with  little  admixture  of  dots  of  a  lighter  color.  The  slides  show 
the  acini  large  with  extensive  papillary  projections  into  them  (Fig. 
124-A)  and  in  many  regions  pronounced  cell  exfoliation  and  degen- 
eration (Fig.  124-B.) 

After-course. — The  morning  of  the  operation  she  had  temperature 
99°,  pulse  100,  respiration  24.  Two  hours  after  operation  tempera- 
ture was  97°.  The  evening  of  the  day  of  operation  temperature 
101.4°,  pulse  140,  respiration  40.     The  succeeding  morning  the  tem- 


DISEASES    OF    THE    THYROID    GLAND 


249 


perature  came  to  normal  and  in  the  evening  went  to  104°.  The  next 
morning  the  temperature  dropped  again  to  normal  and  was  99.6°  at 
10  o'clock,  but  by  3  p.m.  it  had  risen  to  106  (Fig.  125).  She  died  that 
evening.     The  pulse  gradually  rose  from  the  beginning  of  the  post- 


■  :tt«rvIo«  - 

Prof.   . 

Dr.o)  O    'S,    ^ 

Date  _<i- '.i-Cv.'- -._„1.<2- .--.!...'.7- 


-#E  HALSTEAt)  HOSPITiS^ 


uo./r^n) 

Na^VS5...ikOe^V-'*^r><-^C(^coupati  =  n - ^- Afl.     


I     ., 


O 


3T 


.'1 


/ 


,1  ;  w    r 


Fig.    125.— Temperature    curve   in   a   fatal    case    of   exophthalmic    goiter. 


250  CLIXIC'AI^    SL-RGERY    BY    CASE    HISTORIES 

operative  period.  During  this  interval  she  had  a  small  amount  of 
light  yellow  emesis  a  number  of  times  and  took  but  little  nourishment. 
Comment. — The  attempt  to  stay  the  progress  of  the  disease  by  op- 
eration was  the  rankest  folly.  The  pulse  quieted  when  she  was  placed 
in  bed  with  the  exhibition  of  sedatives.  Had  this  plan  been  persisted 
in,  the  probabilities  are  that  the  into.xication  would  have  lessened,  the 
appetite  returned,  and  the  weight  would  liavc  been  restored  and  op- 
eration eoukl  b.ave  safely  been  done.  The  time  that  would  have  been 
required  to  bring  this  state  about  probal)ly  would  have  been  from 
three  to  six  months.  Thei'e  is  the  lub.  To  induce  patients  to  submit 
to  such  restraint  is  difficult,  usually  impcssible.  Were  it  not  equally 
dangerous  to  ligate,  tliis  might  be  done,  as  it  usually  serves  to  attacli 
the  patient  to  the  surgeon  and  insures  her  return  at  the  time  when 
operation  is  safe.  Unfortunately  i)ole  ligation  when  the  disease  is  on 
the  ascendancy  is  quite  as  fatal  as  the  more  radical  resection.  It  is 
()iil\-  by  experiencing  disasters  that  the  surgeon  learns  self-restraint 
which  enables  him  to  refuse  operation  when  conditions  are  not  right. 

CASE  19. — A  farmer  aged  twenty-four  came  because  of  a  goiter. 

Jlistor/j. — Two  years  ago  he  noticed  that  he  was  very  nervous  and 
that  he  had  palpitation  of  the  heart  and  that  he  sle])t  liadly.  A 
month  later  he  noticed  an  enlargement  in  the  lower  part  of  the  neck. 
He  had  the  vessels  tied  on  both  sides  several  months  later.  He  im- 
proved very  much  and  was  fairly  comfortable  until  two  weeks  ago 
when  all  the  symptoms  Ijecame  suddenly  woi'se  and  are  now  worse 
than  before  the  vessels  were  tied.  He  has  lost  some  30  pounds  in 
weight. 

Examination. — A  large  pulsating  thyroid  occupies  the  lower  part 
of  the  neck.  The  scars  of  the  ligation  operation  are  plainly  visible. 
The  entire  gland  seems  to  expand  w'ith  each  pulsation.  The  gland 
extends  well  down  to  the  clavicles  and  the  lower  border  can  not  be 
palpated.  The  x-ray  shoAvs  an  indefinite  shadow  extending  below  the 
clavicles.  There  is  marked  exophthalmos  (Fig.  126).  Graetfe's  and 
Kocher's  signs  are  well  marked.  He  has  pronounced  tremor.  The 
AY.b.c.  is  8,000,  the  lymph  cells  are  increased.     Temperature  98.4'. 

Diagnosis. — The  toxicity  of  his  goiter  can  not  be  questioned.  The 
rather  prompt  improvement  following  the  ligation  operation  suggests 
that  the  procedure  may  have  stayed  the  downward  course.  Now  he 
is  Avorse  than  before  and  has  lost  30  pounds  within  a  month.  Opera- 
tion would  be  hazardous.     A  ligation  now  might  be  undertaken  had 


DISEASES    OF    THE    THYROID    GLAXD 


251 


this  procedure  not  been  done  before.  If  ligated  with  catgut,  the 
vessels  most  likely  become  patulous,  in  which  event  they  might  be 
ligated  again.  Observation  would  be  desirable  before  any  treatment 
is  undertaken. 


Fig.   126. — Facial   expression   of  a  pronounced  exophthalmic   goiter   case. 


252  CLINICAL   SURGERY   BY    CASE    HISTORIES 

Treatment. — He  took  bromides  a  short  time  without  benefit.  Re- 
fused to  remain  in  bed. 

After-course. — He  went  about  as  he  pleased  and  died  a  month  later 
of  gradually  increasing  symptoms. 

Comment. — The  onset  originally  was  hyperacute.  Notwithstanding 
this,  the  results  ligation  produced  were  good,  lasting  more  than  a 
year.     I  would  not  have  had  courage  to  ligate  under  such  conditions. 

CASE  20. — A  housewife  aged  thirty-seven  came  to  the  hospital 
because  of  nervousness  and  a  tumor  of  the  neck. 

Ilistorij. — About  fourteen  years  ago,  just  after  the  birth  of  her 
eldest  son,  she  noticed  an  enlargement  of  the  neck.  About  a  year  and 
a  half  later  she  noticed  that  the  mass  was  eidarging.  It  was  treated 
with  iodine  applications  and  internal  medicine.  It  has  grown  grad- 
ually, there  never  being  any  period  of  rapid  growth.  Seven  years 
ago  while  pregnant  with  her  last  baby  she  began  to  notice  a  gradually 
increasing  nervousness.  The  tumor  of  the  neck  seemed  to  press  more 
at  this  time  and  she  could  not  lie  on  her  back  at  night  without  hav- 
ing pressure  sensations  or  a  choking  feeling.  After  the  birth  of  the 
child  the  choking  sensation  ceased,  but  the  nervousness  remained  and 
in  the  last  year  it  has  increased  perceptibly.  She  is  easily  excited 
and  when  in  this  state  she  notices  that  her  heart  beats  more  rapidly, 
but  under  no  other  circumstances.  She  does  not  get  short  of  breath 
on  exertion  or  have  palpitation.  She  has  not  lost  weight.  She  per- 
spires easily  under  nervous  strain.  She  is  inclined  in  the  last  year 
to  worry  about  trifles.  Her  appetite  is  good  and  her  bowels  are 
regular.  Her  menses  have  always  ])een  regular,  and  practically 
wathout  pain.  The  flow  is  profuse  the  first  two  days.  The  day 
before  the  flow  she  has  occipital  headache.  These  stop  when  the 
flow  starts.  She  has  four  children,  eldest  fourteen,  youngest  seven. 
Four  years  ago  she  had  a  miscarriage  and  almost  died  of  hemor- 
rhage. She  had  ]nieumonia  at  eight,  mumps  at  thirteen  and  acute 
articular  rheumatism  at  fourteen. 

Examination. — The  patient  seems  well  nourished,  shows  no  visible 
signs  of  nervousness,  and  does  not  look  acutely  ill.  She  has  a  slight 
exophthalmos;  the  pupils  are  equal,  regular  and  react  to  light  and 
accommodations;  no  van  Graafe,  Stellwag  or  ]\Ioebius.  There  is  an 
enlargement  in  the  neck  the  size  of  a  lemon  attached  to  the  right  lobe 
of  thyroid.     It  is  spherical,  hard,  and  a  little  nodular,  movable  up 


DISEASES   OF    THE    THYROID    GLAND 


253 


Fig.    127-^. — Colloid-toxic    goiter.      The    smaller    nodule    on    the    right    is    a    displaced    thymu.s. 


Fig.    127-B. — The   thymus   nodule   shown    in   the   preceding   cut. 


254 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


and  down  on  swallowinp-.  It  lies  a  little  to  the  right  of  the  midline. 
The  left  lobe  of  the  thyroid  is  also  enlarged.  Xo  visible  pulsation  in 
neck.    Xo  thrill  or  bruit  over  tumor.     Tonsils  small,  pharynx  normal. 


Fig.    127-L. — The    thyir.us    nodule    on    cross    section. 


T^i 


J^J^^'-' 


-■^■f'-^ 


'"V 


ig.  127-D. — Slide  of  the  thymus  *oduie  shown  in  the  preceding  figures. 


DISEASES    OF    THE    THYROID    GLAND  255 

Teeth  all  pulled  except  lower  incisors  and  canines.  Heart  dullness 
extends  from  midsternal  line  to  9^4  cm.  to  left  of  sternum.  Apex  beat 
in  fifth  interspace.  Systolic  murmur  heard  best  at  apex  transmitted 
to  axilla  and  along  left  side  of  sternum.  It  is  a  soft,  blowing  murmur. 
Pulse  taken  at  Uvo  different  times  was  105  and  120. 

Diagnosis. — This  obviously  is  an  example  of  thyroid  intoxication 
implanted  on  a  long  existing  "simple  goiter."  There  is  no  loss  of 
weight,  and  radical  operation  may  safely  be  undertaken  without  any 
preparatory  treatment. 

Treatment. — The  removal  of  all  of  the  right  lobe  of  the  thyroid 
and  a  piece  of  the  lower  end  of  the  left  was  done.  The  right  lobe 
was  as  large  as  the  fist  and  w^as  firmly  adherent  to  the  anterior  and 
right  side  of  the  trachea.  It  was  separated  from  its  capsule  with 
difficulty.  The  left  lobe  was  enlarged  more  than  was  ajDparent  before 
operation.  A  piece  the  size  of  an  egg  extended  down  behind  the 
sternum.     This  piece  was  removed. 

Pathology. — The  interest  in  this  case  centers  in  the  unexpected 
pathologic  findings.  The  right  lobe  presented  the  irregular  bosse- 
lated  appearance  of  a  colloid  goiter  (Fig.  121 -A).  It  showed  exten- 
sive areas  of  degeneration  of  the  entire  tissue.  The  portion  of  the 
left  lobe  representing  a  somewhat  encapsulated  mass  (Fig.  127-5), 
was  more  elastic  than  is  usual  in  thyroid  lobes.  The  section  showed 
a  pale  whitish  surface  which  was  uniformly  granular.  (Fig.  127-C). 
The  slide  shows  a  general  lymphatic  tissue  with  areas  of  epithelial 
cells  embedded  within  it.  These  cells  in  many  places  are  arranged 
about  a  deeply  staining  structureless  center  (Fig.  127-Z)).  This  nod- 
ule obviously  represents  a  displacement  of  a  portion  of  thymus. 

After-course. — There  was  no  apparent  shock  following  the  opera- 
tion. The  second  day  the  pulse  was  125,  temperature  100.4°  and 
the  patient  was  a  little  nervous.  The  temperature  did  not  go  higher 
and  after  the  second  day  the  patient  rested  easily,  temperature  and 
pulse  gradually  subsided.  The  after-course  was  entirely  uneventful. 
At  no  time  were  there  toxic  symptoms.  On  dismissal  temperature 
was  normal,  pulse  90 ;  there  was  no  apparent  nervousness,  the  wound 
was  entirely  healed,  but  the  neck  was  still  much  swollen.  She  has 
since  reported  that  she  feels  perfectly  well. 

Comment. — Unless  all  material  from  the  operating  room  is  syste- 
matically examined,  many  interesting  things  will  be  overlooked. 


CHAPTER  VII 

DISEASES  OF  THE  CHEST  AND  SPINE 

The  thoracic  cavity,  like  the  cranial,  is  subject  to  attack  by  sur- 
geons about  the  periphery  only.  Nevertheless,  those  diseases  capable 
of  surgical  cure  are  numerous  and    for  the  most  part  are  badly  done. 

DISEASES  OF  THE  MEDIASTINUM 

laitil  the  development  of  goiter  and  thymic  surgery  the  medias- 
tinum was  an  inaccessible  field  to  the  surgeon  except  in  rare  instances 
and  for  those  disposed  to  do  technical  stunts.  Now  that  substernal 
goiters  offer  easy  and  almost  certain  results  there  is  a  new  stimulus 
to  the  study  of  subcostal  diseases.  Furthermore  the  efficiency  of  the 
x-ray.  in  certain  mediastinal  malignancy,  is  so  striking  that  the  early 
identification  of  these  growths  is  but  little  less  important  than  the 
discovery  of  substernal  goiters.  Contrasted  with  these  are  the  aneu- 
rysms and  the  metastatic  nodules  of  malignancies,  and  finally  rare 
conditions  that  simulate  tumors  but  which  are  not. 

CASE  1. — A  retired  farmer  aged  sixty-eight  came  because  of 
hoarseness,  difficulty  in  swallowing-  and  cough. 

History. — His  trouble  began  three  years  ago  with  an  attack  of 
grippe.  He  was  sick  with  an  indefinite  ailment  three  days.  When 
he  got  up,  he  was  hoarse  and  this  has  never  improved,  but  seems 
to  have  become  worse  lately.  A  year  or  more  ago  he  began  to 
cough.  The  cough  bothers  him  but  little  Avhen  he  is  lying  down.  He 
raises  but  little  sputum.  Recently  the  amount  expectorated  has 
much  increased.  For  two  years  he  has  had  difficulty  in  swallow- 
ing. He  has  had  little  difficulty  in  swallowing  fluids,  but  solids 
often  regurgitate  and  the  attempt  to  swallow  brings  on  coughing, 
and  during  the  coughing  spell  the  food  is  apt  to  be  expelled.  Some- 
times after  he  has  eaten  solid  food  and  then  stoops  over  the  food 
is  expelled  in  the  same  state  as  when  he  ate  it. 

Examination. — The  patient  looks  haggard  and  weary  and  speaks 
with  a  rough  voice  which  only  at  times  breaks  above  a  whisper.     His 

256 


DISEASES    OF    THE    CHEST   AND    SPINE 


257 


cougli  is  brassy  and  unproductive.  The  chest  is  barrel-shaped  and 
moves  imperfectly  with  respiration.  The  breath  sounds  in  front  are 
normal  but  expiration  is  somewhat  prolonged,  vocal  fremitus  is  faint. 
The  percussion  note  behind  is  somewhat  high  pitched  and  vocal  sounds 
are  but  faintly  heard.    There  is  substernal  dullness  above  the  angle. 


Fig.  12S.-A  slight  bulging  due  to  the  goiter  is  seen  above  the   sternoclavicular  joint. 


258 


Clinical  surgery  by  case  sistorieS 


The  apex  is  in  tlie  fiftli  interspace  two  fingers  to  the  left  of  tlie  mid- 
clavicle  line.  The  sounds  are  clear,  the  aortic  accentuated.  He  has 
pyorrhea  and  chronic  pharyngitis.  The  right  vocal  cord  is  paralyzed. 
The  finger  placed  over  the  substernal  notch  receives  an  impulse  when 
the  patient  coughs.  A  slight  bulging  can  be  made  out  above  the  left 
sternoclavicular  joint  Avhen  the  patient  cranes  his  neck  forward  and 
to  the  right  (Fig.  128).  The  x-ray  shows  a  wide  aortic  arch  and 
a  shadow  behind  the  upper  portion  of  the  sternum.  This  shadow 
is  much  widened  when  the  patient  takes  a  cup  of  barium  milk.     The 


Fig.    129. — A.  Gross    appearance    of   the    goiter.      B.  The    same    on    cross    section. 

stomach  tube  passes  three  inches  down  the  esophagus  and  comes  to 
a  sudden  stop.    Laboratory  examinations  were  negative. 

Diagnosis. — The  x-ray  excludes  aneurysm — an  unlikely  possibility 
in  a  man  of  his  age.  The  onset  was  more  sudden,  and  the  duration 
too  long  for  a  carcinoma,  and  the  site  of  the  obstruction  too  high. 
However,  this  appeared  to  be  the  presumptive  diagnosis  until  a  sub- 
sternal tumor  was  discovered.  The  location,  mobility  and  smootli  sur- 
face of  this  indicated  a  thyroid.  The  sudden  onset  was  not  accounted 
for  on  this  score,  but  the  mobility  excluded  dermoid  or  lipoma. 

Treatment. — The  thyroid  was  easily  removed.  The  patient's  efforts 
at  coughing  produced  on  request  aided  materially  in  the  elevation  of 
the  gland.    Coughing  ceased  as  soon  as  the  thyroid  was  elevated  above 


DISEASES    OF    THE    CHEST    AND    SPINE  259 

the  sternal  notch.  The  deep  cavity  remaining  was  drained  with  a 
small  soft  rubber  tube. 

Pathology. — The  tumor  removed  was  the  size  of  a  small  orange.  It 
was  somewhat  bosselated  and  fairly  firm.  The  cut  surface  showed  a 
large  cavity  filled  with  a  firm  clot  with  smaller  areas  of  thyroid  tis- 
sue at  one  extremity  (Fig.  129).  The  slide  showed  a  simple  colloid 
goiter. 

After-course. — The  patient  was  quite  comfortable  following  the 
operation,  being  completely  freed  from  his  cough,  and  respiration 
was  unhindered.  He  did  have  much  trouble  with  accumulations  of 
mucus  in  the  throat  which  he  had  difficulty  in  removing.  The  night 
of  the  second  postoperative  day  he  was  given  a  drink  of  water  at  3  :15. 
At  5  o  'clock  the  nurse  heard  a  groan  and  going  to  his  side,  found  him 
dead.  The  wound  was  examined  and  found  free  from  blood  clots  or 
other  disturbance.    Death  likely  was  due  to  embolism. 

Comment. — The  sudden  onset  of  his  trouble  can  be  accounted  for 
most  likely  by  a  hemorrhage  taking  place  in  a  cystic  thyroid.  Un- 
less sought  for,  substernal  goiters  may  easily  be  overlooked.  The 
first  time  I  saw  this  patient  I  did  not  even  suspect  a  goiter,  the  as- 
sumption being  that  he  had  a  carcinoma,  though  malignant  tumors 
in  this  part  of  the  esophagus  are  rare. 

CASE  2. — A  matron  aged  twenty-three  came  to  the  hospital  be- 
cause of  difficulty  in  breathing*. 

History. — The  patient  has  always  enjoyed  good  health.  In  Novem- 
ber, 1911,  she  noticed  seme  difficulty  in  respiration  and  had  some 
sense  of  fullness  in  the  neck.  Soon  afterward  a  bulging  was  noticed 
above  the  breast  bone.  She  consulted  several  surgeons,  who  made 
a  diagnosis  of  mediastinal  sarcoma  and  refused  treatment. 

Examination. — A  bulging  in  the  suprasternal  notch  was  apparent 
on  inspection.  The  skin  covering  this  area  was  slightly  reddened.  On 
palpation  the  tumor  was  slightly  tender  to  touch  and  presented  a  soft 
semifluctuating  resistance.  The  mass  extended  2  cm.  above  the  upper 
border  of  the  sternum  and  was  hidden  by  the  sternomastoid  muscles 
on  either  side.  There  was  no  bulging  of  the  sternum  or  of  the  costal 
cartilages.  On  percussion  there  was  dullness  extending  on  either 
side  of  the  sternal  borders  and  downward  as  far  as  the  angle. 

Diagnosis. — Because  of  the  reddened  skin  and  boggy  feel  of  that 
portion  of  the  tumor  accessible  to  palpation,  the  diagnosis  of  dermoid 


260  CLIXICAL    SURGERY   BY    CASE    HISTORIES 

was  suggested,  because  of  the  close  resemblance  to  the  appearance 
and  consistency  of  irritated  wens.  This  opinion  was  strengthened  by 
the  globular  outline  of  the  substernal  dullness.  Sarcoma  was  ex- 
eluded  because  of  the  consistency  of  the  palpable  portion  of  the 
tumor  and  because  only  the  upper  portion  of  the  mediastinal  space 
was  occupied  by  the  tumor.  A  number  of  conditions  must  be  con- 
sidered. 

Aneurysm. — Those  confined  to  the  retrosternal  space  or  that  im- 
mediately adjoining  will  suggest  the  more  frequent  aneurysm.  The 
absence  of  beats  of  pulsation  is  the  sign  to  be  relied  upon.  The 
presence  or  absence  of  the  AVassermann  reaction  may  be  of  some  value. 
Frequently  the  earh'  age  of  the  individual  is  of  importance. 

Tuherculosis. — In  a  few  instances  tuberculosis  has  been  diagnosed, 
owing  to  the  dullness  in  the  upper  part  of  the  lungs  associated  with 
expectoration.  The  absence  of  bacilli  should  be  enough  to  warrant 
care  in  making  such  a  diagnosis.  Tuberculosis  existed  as  a  complica- 
tion in  five  cases. 

Empyema. — The  history  of  pain  and  dyspnea  with  the  presence  of 
fluid  in  the  lower  chest  has  led  to  error  in  diagnosis.  Examination 
of  tlic  eontciits  olitaiiit'd  by  aspiration  should  be  distinctive.  In 
those  rare  instances  in  which  there  is  a  pleural  exudate  associated  with 
the  intrapulmonary  dermoid  and  only  the  contents  of  the  former  is 
obtained  at  aspiration,  error  is  very  likely,  and  the  operator  may  con- 
sider himself  fortunate  if  he  orientates  himself  during  the  course 
of  the  operation. 

Malignant  Tumors. — The  malignant  tumors  which  are  primary  in 
the  mediastinum  usually  run  their  course  rapidly  in  contradistinc- 
tion to  the  long  history  of  the  dermoids.  However,  if  a  dermoid  be- 
comes infected,  the  increase  in  size  may  be  even  more  rapid  than  in 
malignant  tumors.  Nevertheless,  some  of  the  dermoids  have  presented 
such  urgent  problems  that  a  history  was  not  available.  Though  the 
roentgen  rays  have  been  employed  in  but  a  few  cases  of  mediastinal 
dermoids,  it  is  quite  possible  that  the  irregular  masses  of  mediastinal 
malignancies  might  be  distinguished  from  the  more  sacular  dermoids. 
If  the  latter  contained  calcareous  material,  teeth  or  other  bony  struc- 
tures, diagnosis  might  be  aided. 

Benign  Tumors. — Lipomas  and  tumors  of  the  thymus  have  pre- 
sented pictures  that  might  have  been  confused  with  mediastinal  der- 
moids.    In  such  cases  aspiration  or  diagnostic  incision  alone  could 


DISEASES    OF    THE    CHEST   AND    SPINE  261 

present  a  positiye  answer.  With  perfected  teclmic  it  is  to  be  hoped 
that  more  frequent  diagnostic  operations  will  be  nndertaken. 

Treatment. — Operation  was  begun  by  exposing  the  upper  portion 
of  the  mediastinum.  A  transverse  incision  was  made  over  the  uj)per 
border  of  the  sternum,  extending  well  beyond  the  insertion  of  the 
sternomastoid  muscle  on  the  left  side.  The  insertion  of  the  muscle 
was  severed.  The  superior  pole  of  the  globular  tumor  was  thus 
readily  exposed.  This  was  freely  incised  and  a  grayish-yellow,  greasy 
fluid  escaped.  After  this  was  sponged  out,  a  mass  the  size  of  a  wal- 
nut presented.  This  was  covered  with  fine  lanugo-like  hair  of  the 
color  of  a  newly  hatched  gosling.  The  appearance  of:  this  mass  es- 
tablished the  diagnosis  without  question. 

The  operation  was  completed  by  the  removal  of  the  mass  and  the 
exsection  of  as  much  as  possible  of  the  sac.  The  part  adjacent  to  the 
sternum  was  readilj?"  removed ;  that  of  the  lateral  borders  caused 
greater  apprehension.  The  posterior  wall  of  the  cyst  was  in  close 
apposition  with  the  large  vessels  of  the  neck,  and  was  allowed  to 
remain.  The  cavity  was  swabbed  out  with  iodine  and  the  wound 
was  closed,  except  for  a  small  opening  admitting  a  drain.  This  was 
removed  a  week  later,  and  the  wound  rapidly  became  closed,  and  has 
remained  so. 

Pathology. — The  mass  removed  presented  a  dermal  surface  studded 
with  the  fine  hair  above  noted.  On  section  the  mass  showed  a  fatty 
tissue,  save  for  the  epidermal  covering  (Fig.  130).  On  microscopic 
examination  stratified  squamous  epithelium  and  sweat  and  sudorif- 
erous glands  with  hair  follicles  were  noted  (Fig.  131).  The  cyst  wall 
was  of  the  same  structure,  save  that  hair  was  much  less  abundant 
and  the  glands  sparse.  There  were  no  more  highlj^  organized  tissues 
present. 

Comment. — The  presence  of  these  is  most  frequently  manifested  by 
cough  and  d^'spnea,  less  often  as  pain  from  pressure.  Cough  when 
due  to  pressure  is  caused  by  irritation  of  the  nerves.  Cough  of  another 
type  is  caused  by  irritation  of  the  bronchi  when  perforation  is  im- 
pending. When  due  to  irritation  the  character  of  the  cough  is  simi- 
lar to  that  noted  in  pressure  from  aneurysm. 

Dyspnea  seems  to  be  due  to  direct  i^ressure  on  the  trachea  or 
bronchi,  or  from  pressure  upon  and  displacement  of  the  lungs. 
When  from  causes  usually  unknown,  the  tumor  becomes  the  source 
of  reactive  inflammation,  phenomena  of  a  more  violent  character  are 


262 


CLIXICAL    SURGERY    BY    CASE    HISTORIES 


induced.  The  cause  for  this  irritation  is  not  clear.  The  gradually 
increasing  amount  of  the  cyst  contents  probably  undergoes  some 
chemical  change  which  inflames  the  sac  and  irritates  the  environ- 
ment.    Tn   tliis   tlicy   imitate   the   life   history   of  -wens.      This  simi- 


Fig.    130. — Cross   section   of   a    retrosternal    dermoid. 


Fig.    131. — Slide   from  a   dermoid   of  the   mediastinum. 

larity  of  reaction  to  that  so  often  noted  in  wens  was  the  condition 
that  suggested  the  diagnosis  in  my  patient.  Pleurisy  has  often  been 
diagnosed  in  such  instances,  and  often  exudation  about  the  tumor 
has  resulted,  which  gave  rise  to  the  diagnosis  of  pneumonia.     Often 


DISEASES    OF    THE    CHEST    AXD    SPIXE  263 

the  tnmor  has  been  accidentally  encountered  Trhen  supposedly 
pleural  exudates  have  been  attacked  surgically.  AYhen  the  bronchi 
are  irritated,  perforation  into  them  during  attacks  of  coughing  has 
been  noted  in  three  cases.  The  attendant  expectoration  of  other 
grumous  material  and  hair  has  led  to  a  positive  diagnosis  more 
often  than  any  other  factor.  The  invasion  of  the  bronchus  by  the 
tumor  seems  to  be  in  the  nature  of  a  pressure  necrosis,  often  en- 
hanced by  a  secondary  infection  of  the  tumor  contents.  The  irri- 
tation of  the  bronchus  is  responded  to  by  the  production  of  glassy 
mucus.  After  jDerforation.  honey-like  fluid,  atheromatous  material, 
and  hairs  have  often  been  observed.  Clubbing  of  the  fingers  and 
toes  has  been  noted. 

The  greatest  possible  variations  in  their  topographical  relations 
have  been  noted  in  dermoids  of  the  mediastinum.  The  typical  loca- 
tion of  the  simple  dermoid  is  represented  by  my  own  case,  a  sac 
occupying  the  space  between  the  sternum,  great  vessels,  pericar- 
dium, and  soft  tissues  covering  the  episternal  notch.  Every  possi- 
ble variation  has  been  reported.  One  existed  as  a  small  egg-sized 
cyst  in  the  upper  part  of  the  lung  near  the  hylus.  while  others  oc- 
cupied the  mediastinal  space  and  projected  boldly  out  into  the 
pleural  cavity,  and  some  extended  from  the  sternum  to  the  dia- 
phragm, markedly  displacing  the  lung.  In  one  instance  a  retro- 
sternal dermoid  communicated  by  a  small  sinus  with  a  similar 
tumor  external  to  the  sternum. 

CASE  3. — A  minister  aged  thirty-six  came  because  of  pain  in  his 
arm  and  difficulty  in  breathing. 

History. — Two  years  ago  he  had  pains  in  the  left  arm  which  were 
called  neuritis.  These  were  particularly  bad  during  the  past  winter 
and  with  intermissions  these  have  continued  to  date.  Six  months 
ago  he  began  to  have  huskiness  of  speech.  Eecently  he  has  noticed 
difficulty  with  respiration,  particularly  on  exertion.  Six  months  ago 
he  noticed  an  enlargement  above  the  left  collar  bone.  This  has  re- 
mained so  since.  He  has  had  cough  at  intervals,  but  has  not  ex- 
pectorated. 

Examination.- — There  is  a  bulging  above  the  left  clavicle.  This  is 
firm,  elastic  to  pressure.  There  is  marked  substernal  dullness  on  per- 
cussion extending  to  the  junction  of  the  third  rib  and  laterally  to 
near  the  midsternal  border.     The  apex  beat  is  in  the  sixth  inter- 


264 


CLINICAL    SURGERY   BY    CASE    HISTORIES 


Fig.    132. — Lymphosarcoma    of   the    mediastinui: 


DISEASES    OF    THE    CHEST   AND    SPINE  265 

space.  The  breath  sounds  in  the  upper  portion  of  the  left  lung  are 
diminished.  There  are  no  enlarged  lymph  glands.  The  x-ray  shows 
a  shadow  beneath  the  upper  end  of  the  sternum  and  extending  lat- 
erally as  indicated  b}^  the  percussion  line  above  mentioned  (Fig.  132). 
The  Tocal  cords  are  not  paralyzed. 

Diagnosis. — The  neuralgic  j)ains  of  two  years  ago  probably  were 
due  to  this  tumor.  The  dyspnea  indicates  a  bronchial  pressure.  This 
sequence  suggests  a  posterior  mediastinal  involvement.  This  is  a 
relatively  slow  growth  which  indicates  its  origin  in  a  lymph  gland. 
There  being  no  other  glands  involved,  Hodgkin's  disease  may  be 
excluded. 

Treatment. — Arsenic  was  given  and  he  was  advised  to  have  x-rays 
used. 

After-course. — He  did  not  follow  the  suggestion  to  use  the  x-ray 
for  three  months.  At  this  time  he  was  cyanosed  and  scarcely  able 
to  exert  himself  at  all.  The  left  recurrent  larj'ugeal  nerve  was  in- 
volved. He  now  submitted  to  x-ray  treatment  and  was  improved 
at  once.  After  undergoing  treatment  for  a  number  of  months,  he 
was  free  from  symptoms  and  the  x-ray  showed  nothing  of  the  retro- 
sternal shadow.     That  has  continued  now  a  year. 

Comment. — This  case  may  yet  terminate  as  a  typical  Hodgkin. 
The  increasing  cyanosis  is  usually  the  lot  of  such  cases.  The 
x-ray  produced  marked  temporary  relief  and  it  has  endured  longer 
than  is  usual  in  such  cases. 

CASE  4. — I  w^as  called  to  see  a  housewife  aged  fifty-six  because 
of  difiiciilt  respiration. 

History. — The  patient  has  always  enjoyed  good  health,  never  had 
any  lung  trouble.  A  year  and  a  half  ago  she  had  the  left  breast  re- 
moved for  carcinoma.  Three  months  ago  she  began  having  attacks 
of  dyspnea,  not  relieved  by  usual  remedies.  After  much  coughing 
she  is  able  to  raise  a  little  sputum  lightly  tinged  with  blood. 

Examination. — The  patient  is  bolstered  upright  in  bed  and  con- 
stantly coughs  in  short,  nonproductive  expulsive  efforts.  After  much 
labor  a  little  bloody  sputum  is  raised.  The  trachea  does  not  move 
in  the  forced  expiratory  efforts.  Inspiration  and  expiration  seem 
equally  impeded.  The  percussion  note  over  the  lungs  seems  un- 
changed other  than  a  moderate  emphysematous  increase  in  resonance. 
Over  the  sternum  in  the  region  of  the  angle  is  an  elliptical  area  of  flat- 


2G6 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


ness  directed  transversely  to  the  long  axis  of  the  sternum  (Fig.  133). 
A  few  large  rales  are  heard  over  the  lungs,  especially  over  the  lower 
scapuhir  region.  The  heart  sounds  are  clear,  the  second  pulmonary 
somewhat  accentuated.  The  attending  physician  suspects  a  substernal 
goiter.  The  dullness  lies  too  deep.  There  is  a  resonance  between  the 
dullness  and  the  suprasternal  notch.  The  development  of  the  symp- 
toms is  too  rapid  for  goiter  and  finally  the  sparse  blood-stained 
sputum  speaks  unmistakably  for  malignancy. 


Fig.   133. —  Schematic  representation  of  the  area  of  dullness  in  a  case   of  metastatic  carcinoma 

of   the    mediastinum. 


Diagnosis. — The  fact  that  the  patient  had  a  carcinoma  of  the  breast 
removed  a  year  and  a  half  ago  and  now  has  a  mediastinal  dullness 
and  d^'spnea  is  sufficient  to  warrant  the  suspicion  that  there  is  a  met- 
astatic carcinoma  of  the  mediastinum.  The  sparse,  frothy  sputum 
faintly  tinged  with  blood  indicates  that  there  are  cancer  nodules  in 
the  substance  of  the  lung  as  well  as  mediastinal  mass.  Blood-tinged 
sputum  is  not  prone  to  attend  peribronchial  infiltrations. 

'Treatment. — None.     Morphine  to  control  the  cough. 

After-course. — The  patient  died  in  increasing  dyspnea  within  twer- 
ty-four  hours. 


DISEASES    OF    THE    CHEST   AND    SPINE  267 

Comment. — In  a  patient  who  has  been  operated  on  for  malignancy 
any  disease  occurring  afterwards  is  likely  to  be  caused  by  cancer 
metastasis,  and  this  possibility  should  always  be  carefully  considered 
before  an  independent  disease  is  diagnosticated. 

CASE  5. — A  farmer  aged  thirty-six  came  because  of  cough  and 
dyspnea. 

History. — The  patient  complains  of  cough  and  dyspnea.  For  three 
years  he  has  noticed  dj^spnea  at  times  with  cough.  He  tried  various 
asthma  cures  and  changes  of  climate  without  marked  benefit.  More 
recently  dyspnea  has  been  most  marked  on  exertion.  His  cough  is 
nonproductive  and  he  has  noticed  that  it  is  difficult  for  him  to  get 
his  breath  in  as  well  as  to  get  it  out,  as  he  has  read  is  the  case  with 
asthmatics. 

Examination. — The  patient  is  well  nourished.  The  chest,  save 
for  a  chest  that  approaches  the  barrel  shape,  appears  normal.  It  is 
hyperresonant  on  percussion.  The  breath  sounds  are  somewhat  fee- 
ble, considering  the  well-shaped  chest,  and  there  are  numerous  me- 
dium-sized rales  most  marked  at  the  lower  angle  of  the  scapula.  The 
apex  beat  is  in  the  fourth  interspace  at  the  nipple  line.  There  is 
substernal  dullness  as  far  as  the  angle  and  beyond  the  right  sternal 
margin,  where  the  x-ray  shows  a  shadow  beneath  the  sternum  which 
corresponds  to  the  area  of  dullness  (Fig.  134).  The  patient  re- 
counts that  he  had  a  fibrous  tumor  removed  from  the  upper  part  of 
the  calf  of  the  leg  which  was  removed  four  or  five  years  ago.  It 
was  examined  by  a  pathologist  who  pronounced  it  a  fibrous  tumor. 

Diagnosis. — The  physical  signs  and  x-ray  indicate  a  substernal 
tumor.  There  are  none  of  the  circulatory  or  vascular  symptoms  of 
aneurysm.  Its  peculiar  lobulations  likewise  would  exclude  its  ori- 
gin from  the  vessels.  The  knowledge  that  the  fibroids  situated  in 
the  calf,  though  presenting  in  general  the  appearance  of  pure  fibro- 
mas,  are  in  reality  fibrosarcomas,  and  unless  widely  excised,  are 
prone  to  return.  This  knowledge  together  with  the  x-ray  picture 
and  the  physical  findings  is  sulficient  to  warrant  the  diagnosis  of 
metastatic  sarcoma  of  the  mediastinum. 

Treatment. — He  was  referred  to  an  expert  roentgenologist  who 
rayed  him  vigorously  half  a  dozen  times. 

After-course. — Notwithstanding  the  above  treatment  improvement 
was  not  marked,  though  there  was  no  perceptible  advance  during  the 
course  of  the  treatment. 


268 


CLINICAL    SURGERY   BY    CASE   HISTORIES 


Cow/ment. — The  fibromas  of  the  calf  demand  careful  excision  to- 
gether with  a  margin  of  surrounding  tissue.  They  usually  mani- 
fest their  malignancy  by  local  recurrence,  but  may,  as  in  this  case, 
show  metastasis.    The  x-rav  in  tumors  of  this  kind  is  less  useful  than 


Fig.    134. — Metastatic    sarcoma   of   the    mediastinum. 


in  tumors  arising  in  the  lymph  glands  primarily.  These  tumors 
tend  to  metastasize  in  lymph  glands,  which  fact,  together  with  the 
disposition  to  recur  locally,  would  align  them  clinically  with  the  en- 
dotheliomas, but  notwithstanding  this,  their  structure  is  that  of 
fibrosarcoma. 


DISEASES    OF    THE    CHEST   AND    SPINE 


269 


CASE  6. — A  soldier  aged  twenty-four  came  to  the  hospital  be- 
cause of  dyspnea. 

History. — He  has  three  aunts  who  have  tumors  of  the  womb  prob- 
ably uterine  mvomas.  He  first  noticed  a  growth  at  the  right  border 
of  the  breast  bone  five  years  ago.  It  remained  stationary  for  a  year 
or  more   and  then  gradually   grew.     During   the   past   year   it  has 


Fig.   135.— Buk 


;  of  the  left  border  of  the  sternum  and   enlargement  of  the   cervical  lymph 
glands  in  a  case  of  lymphosarcoma  of  the  mediastinum. 


grown  rapidly.  It  caused  him  no  trouble  until  the  past  year.  Since 
then  he  has  been  short  of  breath.  Recentlj^  his  left  arm  has  been 
swollen  and  painful.  He  has  noticed  lumps  in  the  groin  and  under 
the  arms  for  six  months  or  more. 

Examination. — ^A  mass  the  size  of  a  split  cocoanut  occupies  the  left 
border  of  the  sternum  and  left  breast.  It  is  fairly  dense  but  dis- 
tinctly elastic.  The  skin  is  unattached  to  it  but  the  tumor  does  not 
move  on  manipulation.     There  is  a  mass  the  size  of  a  walnut  in  the 


270 


CLINICAL    SURGERY   BY    CASE    HISTORIES 


left  groin.  Both  axillfe  are  filled  with  enlarged  glands,  most  of  them 
being  the  size  of  a  hickory  nut  to  a  walnut.  The  glands  of  the 
lower  cervical  triangle  are  markedly  enlarged  (Fig.  135).  The  up- 
per glands  of  the  neck  are  not  involved.     The  superficial  inferior- 


Fig.  136. — Lymphosarcoma  of  the  mediastinum. 

epigastric  veins  are  much  dilated.  There  is  dullness  in  front  over 
the  tumor  and  about  its  border.  The  resonance  is  fairly  clear  on 
the  back.  The  x-ray  shows  a  wide  shadow  behind  the  sternum  (Fig. 
136). 


MSEASES    OF    THE    CHEST   AND    SPINE  271 

Diagnosis. — The  primary  tumor  sounds  like  a  mediastinal  tumor. 
The  occurrence  of  the  manr  discrete  enlarged  glands  is  pathog- 
nomonic of  Ijonphoma. 

Treatment. — X-ray  treatment  was  advised. 

After-course. — Treatment  was  not  persevered  in;  six  months  later 
he  presented  a  large  ulcerous  mass  which  protruded  at  the  left  bor- 
der of  the  sternum. 

Comment. — It  is  remarkable  that  he  should  have  been  able  to  con- 
tinue the  duties  as  a  soldier  with  such  an  enormous  mass  in  his 
chest. 

Case  7. — A  barber  came  to  the  hospital  because  of  general  pains, 
most  pronounced  under  his  breast  bone. 

History. — He  had  always  had  good  health,  when  he  began  to  have 
pain  in  various  joints,  particularly  in  the  elbows  and  ankles.  He 
has  severe  pain  in  the  breast  bone  which  he  ascribed  to  an  injury 
he  received  six  months  before  by  being  struck  by  a  limb  of  a  falling 
tree. 

Examination. — None  of  the  joints  complained  of  show  any  limitation 
of  motion  or  pain  on  manipulation.  There  is  marked  tenderness 
on  pressure  over  the  sternum  at  the  angle  and  just  below.  There 
is  pain  over  the  third  rib  cartilages.  There  is  no  dullness  on  percus- 
sion and  no  difference  in  the  pupils.  The  vocal  cords  are  unaffected 
and  there  is  no  tracheal  tug.  The  x-ray  shows  a  shadow  in  the  me- 
diastinum. The  borders  are  fairly  clear  cut  (Fig.  137).  There  is 
a  slight  general  anemia. 

Diagnosis. — The  sternal  pain  and  the  shadow  in  the  mediastinum 
are  pathognomonic  of  aneurj'sm  and  sternal  periostitis.  A  mediasti- 
nal malignancy  when  it  does  involve  the  sternum  is  not  attended  by 
pain.  Though  he  denies  syphilitic  infection,  he  does  so  with  a  far- 
away look  in  his  eyes  as  though  he  were  harboring  a  memory. 

Treatment. — He  was  given  ascending   doses  of   potassium  iodide. 

After-course. — The  pains  disappeared  in  three  weeks  and  his  gen- 
eral condition  markedly  imj^roved.  He  was  continued  on  mercurial 
treatment  which  he  soon  neglected.  A  year  and  nine  months  after 
the  first  observation,  while  shoveling  snow  a  gush  of  blood  shot  from 
his  mouth  and  he  fell  on  his  face  in  the  snow,  dead. 

Comment. — The  general  appearance  of  the  patient,  the  character 


272  CLIN-ICAL   SURGERY   BY    CASE    HISTORIES 

of  the  periostitis  and  the  evidence  of  the  x-ray  was  amply  confirmed 
by  the  therapeutic  test.  When  these  factors  align  themselves  it 
furnishes  the  most  positive  evidence  of  the  diagnosis  of  syphilis. 


Fig.    137. — Aneurysm   of  the   aorta. 


DISEASES   OP    THE    CHEST   AND    SPINE 


273 


CASE  8. — A  broker  aged  twenty-eig-ht  came  because  of  a  painful 
swelling"  on  his  breast  bone. 

Hisiorij. — For  six  or  eight  weeks  lie  lias  had  pain  over  his  breast 
bone.  It  has  been  painful  at  intervals,  but  in  the  past  week  it  has 
been  increasino-.     "When  he  is  activelv  at  work  he  does  not  mind  it 


Fig.   138. — Gumma  of  the  sternum. 

much  but  when  at  leisure,  particularly  at  night,  the  pain  is  severe. 
His  general  health  is  good  but  he  does  not  have  the  vigor  or  endur- 
ance he  formerly  had.  He  has  been  treated  for  several  weeks  without 
benefit. 

Examination. — Over  the  angle  of  the  sternum  there  is  a  flat  swell- 
ing measuring  5  to  6  cm.  across  and  about  1  cm.  high.     It  is  firm 


274  CI.INICAI.    SrRGKRY    BY    CASE    HISTORIES 

to  the  touch  and  tender  on  deep  pressure.  No  definite  border  can  be 
made  out,  but  it  diffuses  by  stages  into  the  skin  surroundino-.  The 
clavicles  are  not  tender  (Fig.  138). 

Diagnosis. — A  painful  periostitis  coming  in  so  short  a  time  can 
be  nothing  but  syphilis. 

Treatment. — He  was  given  injections  of  mercury  until  the  swelling 
subsided  and  was  then  sent  to  a  syphilologist  for  further  treatment. 

After-course. — He  is  well  now  after  ten  years. 

Comment. — The  sternum  and  clavicles  are  frequent  seats  of  peri- 
ostitis and,  save  for  rare  tuberculosis  of  the  sternoclavicular  articu- 
lation, is  the  only  lesion  that  need  be  kept  in  mind. 

DISEASES  OF  THE  LUNGS 

The  surgical  diseases  of  the  thoracic  cavity  and  the  lungs  are 
few.  None  in  fact,  save  the  drainage  of  purulent  accumulations, 
is  beyond  the  developmental  stage.  Formerly  when  empyemas  were 
not  diagnosed  before  the  hectic  stage  was  reached,  it  was  time 
to  interfere  as  soon  as  they  came  to  the  surgeon.  Now  that  the 
average  practitioner  is  well  (jualified  to  make  a  diagnosis,  pus  is 
usually  detected  early  and  it  devolves  upon  the  surgeon  to  stay 
his  hand  until  there  is  adhesion  between  the  parietal  and  visceral 
pleura.  In  lung  abscess  the  surgeon  usually  must  make  his  own 
diagnosis  as  to  location  even  if  the  patient  is  delivered  to  him  as 
one  likely  suffering  from  an  abscess  of  the  lung.  These  factors 
make  it  desirable  that  the  surgeon  be  equipped  with  a  practical 
knowledge  of  physical  diagnosis. 

CASE  1. — A  married  woman  aged  twenty-five  entered  the  hospital 
because  of  chills,  fever,  sweats,  and  pain  in  the  right  side. 

Historij. — She  had  a  normal  delivery  at  term  on  the  second  of 
December,  1918.  Four  days  after  delivery  she  had  a  chill.  She  does 
not  know  about  fever,  but  thinks  she  had  some.  She  had  chills  after 
that  every  second  or  third  day,  followed  by  intense  sweats.  The 
doctor  said  she  had  fever  but  she  does  not  know  how  much.  She 
felt  pretty  well  between  chills.  After  about  three  weeks  the  chills 
stopped  for  four  or  five  days  and  she  was  able  to  be  up  and  around. 
Had  no  pain  during  that  time.  On  the  sixth  day  after  delivery  both 
legs  below  the  knee  were  puffy. 


DISEASES    OF    THE    CHEST   AND    SPINE  275 

After  the  free  interval  she  had  two  chills  in  one  day.  She  went 
back  to  bed  and  from  that  time  on  she  would  have  chills  on  about 
three  successive  days.  They  would  then  stop  for  a  day  or  two  and 
begin  again.  This  has  kept  up  to  the  present  time,  now  eleven  weeks. 
On  one  day  she  was  told  her  temperature  was  104°.  About  seven 
weeks  after  the  trouble  started  she  had  a  rather  sudden  pain  in  the 
left  side  of  the  chest.  This  was  quite  severe.  She  coughed  some  but 
not  a  great  deal.  Did  not  bring  up  much  and  does  not  cough  much  now. 
The  pain  lasted  about  two  weeks.  At  this  time  about  li/^  pints  of 
a  yellow  watery  fluid  was  drawn  from  the  left  chest  by  her  doctor. 
She  still  has  a  little  pain  in  the  left  chest.  "When  the  fever  comes 
up,  the  breathing  is  difficult.  She  feels  fairly  well  except  on  the 
days  she  has  the  chills.  In  the  past  two  weeks  she  has  had  pain  along 
the  lower  border  of  the  ribs  on  the  right  side. 

Examination. — The  patient  is  not  emaciated,  shows  no  anemia, 
but  is  very  nervous.  Both  legs  are  still  putfy  to  the  knees  and  pit 
on  pressure.  The  patient  states  that  the  swelling  of  the  feet  is  not 
as  great  as  it  was. 

The  chest  shows  the  following  findings :  lungs,  posteriorly,  normal 
resonance  to  percussion  over  whole  right  lung.  Decreased  resonance 
to  percussion  over  whole  left  lung.  Almost  flatness  around  lower 
angle  of  scapula  and  along  the  inner  border  of  the  scapula  half  way 
up.  Auscultation  over  the  whole  right  lung  gives  loud  increased 
breath  sounds.  Breath  sounds  diminish  over  the  whole  left  lung. 
Along  lower  part  of  inner  border  of  scapula  and  lower  angle  of 
scapula  the  breathing  is  almost  tubular  in  character.  The  spoken 
voice  is  increased  over  the  whole  left  lung,  but  especialh'  at  the 
lower  angle  of  the  scapula. 

The  apex  beat  is  felt  just  to  the  left  of  the  sternum.  The  right 
border  of  the  heart  is  to  the  right  of  the  midline.  The  second  pul- 
monary sound  is  relatively  loud.  There  is  tenderness  in  the  hepatic 
region.  The  liver  is  just  palpable.  The  uterus  is  in  position  and 
is  large  and  soft.  There  is  a  boggy  mass  on  either  side,  most 
marked  on  the  left.  The  x-ray  shows  the  right  lung  clear  and  nor- 
mal. A  rather  dense  shadow  is  seen  on  the  left  side  taking  up 
most  of  the  lower  left  lobe. 

Blood :  White  cells  8,400.  Differential  count  about  normal.  Hem- 
oglobin and  red  count  but  little  changed. 


276  CLINICAL    SURGERY   BY    CASE    HISTORIES 

Diagnosis. — Chills  coming  on  four  days  after  labor  suggests  in- 
fection. The  swelling  of  the  feet  on  the  sixth  day  indicates  throm- 
bosis of  the  pampiniform  veins.  The  recurrent  chills  and  sweats  con- 
firm this  evidence  and  the  physical  examination  verifies  it.  The  sud- 
den pain  in  the  left  chest  suggests  a  small  thrombus.  Had  it  been 
large,  dyspnea  would  have  been  more  marked.  Following  this  an 
exudate  formed  in  the  pleural  cavity,  which  was  removed  by  the  doc- 
tor. She  remained  as  sick  as  before  and  has  added  pain  in  the  right 
upper  quadrant  of  the  abdomen.  With  this  history,  consolidation  of 
the  lower  lobe  suggests  an  infection.  The  leucocyte  count  does  not 
bear  this  out  but  the  x-ray  examination  does.  The  abdominal  pain 
is  probably  due  to  congestion  of  the  liver,  the  result  of  slight  dis- 
placement and  increased  labor  of  the  heart.  The  diagnosis  is,  there- 
fore, thrombosis  of  the  peh'ic  veins,  secondary  septic  thrombosis  of 
the  left  lung  with  abscess  formation. 

Treatment. — Feb.  10,  1919.  Seventh  rib  resection  just  below  an- 
gle of  the  scapula.  The  pleura  was  much  thickened.  A  pocket  was 
opened,  this  small  cavity  being  pretty  well  walled  off  by  adhesions. 
Only  a  little  bloody  serous  fluid  escaped.  The  lung  could  be  felt  at 
the  top  of  this  cavity.  It  was  dark  red  in  color  and  felt  firm  to  the 
touch  having  the  consistency  of  liver.  An  aspirating  needle  passed 
(3  to  4  times)  into  the  solid  lung  tissue  revealed  no  definite  abscess 
cavity,  but  showed  only  a  blood^y  serum.  The  cavity  was  drained  with 
gauze. 

After  the  operation  the  temperature  became  normal  for  two  days. 
On  the  third  day  it  went  up  to  102°  and  from  that  time  on  she  ran 
a  septic  temperature,  going  up  to  a  little  over  102^  each  day  up  to  the 
second  oi^eration.    She  had  no  real  chill  after  the  first  operation. 

Second  operation,  Feb.  17,  1919.  An  aspirating  needle  was  passed 
into  the  lung  substance.  Xo  pus  was  found  but  the  whole  lower  lobe 
was  found  solid.  The  needle  was  followed  by  the  electric  cautery  and 
a  rubber  drainage  tube  was  inserted  and  left.  The  cavity  below 
was  packed  with  gauze. 

After-course. — The  patient  ran  a  temperature  of  102°  for  about  two 
days.  It  then  dropped  down  and  has  been  from  normal  to  100.5°  up 
until  today  (Feb.  21).  Quite  a  large  amount  of  greenish-yellow 
pus  has  drained  from  the  wound  but  most  of  it  seems  to  come  through 
the  gauze  pack.  The  general  condition  of  the  patient  has  been 
much  better  since  Feb.  19. 


DISEASES    OF    THE    CHEST    AND    SPINE  277 

March.  2,  1919.  Gauze  pack  removed  from  around  the  drainage 
tube.  There  had  been  considerable  greenish-yellow  pus  drainage  but 
when  the  pack  was  removed  it  was  followed  by  a  profuse  discharge 
of  greenish-yellow  pus.  On  deep  respiration  the  lower  left  lobe 
expanded  and  forced  pus  and  air  out  of  the  chest  cavity. 

Condition  at  dismissal,  March  11,  1919.  The  x-ray  shows  the  rub- 
ber drainage  tube  in  about  the  middle  of  the  lower  left  lobe.  Lung 
shadow  of  lower  left  lobe  approaching  the  normal  in  appearance.  The 
temperature  for  the  last  eight  days  has  never  gone  over  100°.  The 
pulse  is  still  rapid,  at  times  going  up  to  120.  The  drainage  is  puru- 
lent, but  not  very  large  in  amount.  The  patient  feels  well.  She  was  al- 
lowed to  go  home,  retaining  the  tube. 

March  30,  1919.  Patient  returned  for  dressing.  Tube  taken  out 
and  a  smaller  and  shorter  one  substituted.  Small  amount  of  drain- 
age. Breath  sounds  coming  in  lung.  Patient  gaining  in  weight  and 
feeling  well. 

Comment. — The  history  of  the  case  indicated  the  presence  of  a  sep- 
tic thrombosis.  In  spite  of  the  fact  that  the  needle  failed  to  locate 
an  abscess,  the  tube  was  placed  in  the  region  of  the  greatest  den- 
sity. In  the  iDuerperal  lung  infections  there  is  seldom  a  single 
large  abscess  but  a  number  of  small  ones.  In  such  cases  by  intro- 
ducing a  drainage  tube  into  the  area  of  maximum  involvement  these 
separate  areas  of  infection  are  made  to  become  confluent  and  drain 
out  of  a  common  opening. 

CASE  1-A. — A  farmer  aged  forty-six  came  to  the  hospital  because 
of  a  sinus  in  the  left  side. 

History. — One  year  ago  the  patient  was  accidentally  hit  in  the  side 
with  a  stone.  The  skin  was  not  broken  and  there  was  no  swelling, 
soreness  or  sickness  following.  One  month  later  he  fell  and  struck 
the  same  side.  Slight  swelling  followed  but  there  was  no  break  of 
the  skin,  or  sickness,  and  the  soreness  lasted  only  a  short  time.  He 
worked  as  usual  and  paid  no  attention  to  the  soreness.  There  was 
a  swelling  of  skin  over  the  rib  however,  which  remained  all  winter. 
During  harvest  the  swelling  broke  open  and  began  discharging  pus 
and  has  continued  discharging  since.  Three  weeks  ago  he  caught 
a  severe  cold  and  since  has  had  shortness  of  breath  and  temj)erature 
to  103°.  He  took  osteopathic  treatment  which  relieved  it  in  two  or 
three  days.     He  has  had  no  fever  since  and  no  cough  until  a  week 


278  CLINICAL    STRGERY    BY    CASE    HISTORIES 

ago,  wlien  he  began  to  have  occasional  cough.  He  has  suffered  sliort- 
ness  of  breath  until  the  last  two  days,  but  is  better  again.  His  gen- 
eral health  has  always  been  good.  He  had  the  usual  ehiklliood  dis- 
eases, but  no  scarlet  fever,  diphtheria,  pneumonia  or  typhoid.  He 
liad  malaria  at  sixteen.  He  does  not  have  headache,  no  eye,  ear  or 
throat  trouble ;  ]io  bladder  frecpiency  or  pain,  no  Neisser  or  luetic 
infection ;  no  history  of  tuberculosis  in  family.  One  sister  died  of 
cancer  of  intestines  at  sixty.  The  oldest  daughter  of  patient  had 
cancer  of  breast  at  twenty  years.  The  patient's  appetite  has  been 
good  until  the  past  week.  There  has  been  no  loss  of  weight  until 
past  three  weeks,  but  since  then  he  has  lost  17  pounds. 

Examination. — The  patient  is  in  bed  but  does  not  look  acutely  ill. 
He  is  of  large  frame  and  fairly  good  luitrition,  the  skin  is  warm, 
elastic  and  shows  many  small  moles.  There  are  no  glands  palpable  in 
the  neck.  The  chest  is  symmetrical,  the  respiratory  movements  equal 
above,  lessened  below.  There  is  a  sinus  over  the  6th  rib  which  is 
discharging  pus.  The  heart  is  felt  about  9  cm.  left  in  5th  intercostal 
space  and  is  best  heard  here.  The  dullness  of  heart  apex  extends 
to  left  axillary  space.  Below  the  (ith  rib  there  is  a  tympanitic 
note  as  far  as  the  costal  margin.  The  sounds  of  the  heart  at  the 
apex  are  distant,  rapid  and  the  intervals  are  nearly  equal.  At  the 
base  sounds  are  clear,  no  murmurs,  no  abdominal  organs  felt,  no 
masses,  no  tenderness  on  pressure,  no  pain.  X-ray  examination  of 
the  chest  shows  a  shadow  extending  almost  to  the  top  of  the  left  chest. 

Diagnosis. — Obviously  there  is  an  empyema.  From  the  history 
it  seems  likely  that  there  was  an  infected  periostitis  which  infected 
the  pleural  cavity  secondarily.  Localized  infections  of  the  ribs  are 
usually  tuberculous,  but  this  one  likely  is  not  or  if  it  is  tuberculous 
there  must  be  a  mixed  infection. 

Treatment. — The  rib  to  which  the  sinus  extended  was  resected. 
Two  sinuses  were  found  which  communicated  with  the  pleural  cavity. 
The  pleura  was  much  thickened  and  an  area  of  calcification  extended 
around  the  j^arietal  pleura.  The  diaphragmatic  pleura  was  much 
thickened  as  was  the  pleura  over  the  left  lung.  The  cavity  was 
filled  with  a  thin  yellow  pus. 

After-course. — There  was  no  operative  shock.  The  wound  drained 
considerable  thin  yellow  pus  the  first  two  days.  Temperature  the 
second  postoperative  day  went  to  102.5-.  the  highest  after  the  oper- 
ation, pulse  100.     The  gauze  was  removed  from  around  the  tube  the 


DISEASES    OF    THE    CHEST    AXD    SPIXE  279 

third  postoperative  day.  The  thin  purulent  discharge  changed  at 
the  end  of  a  week  to  a  pinkish  yellow.  It  did  not  seem  to  decrease 
in  amount  even  up  to  the  day  of  his  dismissal  from  the  hospital.  He 
ran  a  mildly  septic  course.  The  temperature  dropped  to  about  99 
every  morning  and  went  to  100^  or  101.5^  in  the  evening.  He  suf- 
fered no  pain.  The  drainage  tube  was  not  removed  or  shortened 
when  the  patient  left  the  hospital.  16  days  after  operation.  He  felt 
well  and  had  a  good  appetite.  He  was  allowed  to  go  home  with 
instructions  to  return  in  a  month  for  examination.  It  was  obvious 
that  the  thickened  calcified  pleura  woukl  not  permit  of  a  spontaneous 


Fig.     139. — Transplantation    of    a    pedicled    skin    flap    into    the    thoracic    cavity    in    order    to 
obliterate   a  chronic  empyema. 

obliteration  of  the  cavity.  In  two  months,  after  the  virulence  of 
the  infection  had  abated,  two  ribs  were  resected  and  a  flap  from  the 
anterior  abdominal  wall  was  pushed  up  into  the  cavity  (Fig.  139) 
after  the  thickened  calcified  pleura  had  been  removed.  In  order 
to  facilitate  the  holding  of  the  flap  in  the  deep  cavity  the  tip  was 
grasped  by  an  eight-inch  forceps  and  by  this  means  pushed  into  the 
deep  cavity.  The  handle  of  the  forceps  was  then  fastened  to  a 
rib.  In  two  weeks  the  forceps  was  removed  and  the  flap  was  found 
permanently  adherent. 

Comment. — In  these  chronic  cavities  the  dermatization  by  means 
of  a  pedicled  flap  furnishes  an  efficient  means  of  stopping  suppura- 


280  CLIXICAL   SURGERY    BY    CASE    HISTORIES 

tion.  The  skin-lined  cavity  does  not  annoy  the  patient  in  any  way. 
Holding  the  flap  in  place  by  means  of  a  forceps,  as  indicated,  simpli- 
fies the  otherwise  most  difficult  step  in  the  operation.  This  operation 
is  easily  performed  under  local  anesthesia. 

CASE  2. — A  widow  aged  sixty-two  came  to  the  hospital  com- 
plaining- of  dyspnea. 

History. — The  patient  had  her  riglit  breast  removed  ten  years  ago 
because  of  carcinoma.  She  has  had  no  trouble  since.  Two  years 
ago  she  began  to  have  cough.  She  had  pain  in  the  left  side  with  pain 
on  deep  respiration.  She  has  had  more  or  less  cough  but  no  expec- 
toration.   She  has  dyspnea  on  exertion  and  when  first  lying  down. 

Examination. — She  is  a  very  thin,  pale  woman.  The  breath  sounds 
in  the  front  of  the  chest  are  loud,  the  expiration  is  prolonged  with 
a  high  pitch  as  compared  to  the  average.  Behind  the  left  side  is 
dull  from  the  sixth  rib  down  and  the  breath  sounds  and  vocal  fremitus 
are  much  diminished.  The  heart  sounds  are  normal.  The  x-ray  shows 
a  dark  space  between  the  lung  and  chest  wall  as  though  the  lung 
were  pushed  away. 

Diagnosis. — Pain  in  the  chest  in  a  person  who  has  been  operated 
on  for  carcinoma  of  the  breast  suggests  a  vertebral  metastasis  and 
dyspnea,  a  mediastinal  growth.  The  lung  findings  together  with  the 
x-ray  findings  suggest  a  simple  pleural  exudate. 

Treatment. — Five  hundred  c.c.  of  a  clear  exudate  was  removed  by 
aspiration. 

After-coicrse. — The  patient  was  much  relieved  by  the  aspiration,  but 
the  fluid  reaccumulated  and  aspirations  had  to  be  repeated.  She 
gradually  weakened  and  died  six  months  later. 

Autopsy. — There  was  a  metastatic  carcinoma  the  size  of  a  lemon 
about  the  left  brachial  tree.     There  was  no  vertebral  metastasis. 

Comment. — The  pain  complained  of  apparently  was  due  to  in- 
volvement of  the  intercostal  nerves  near  their  exit. 

CASE  3. — A  fanner  boy  aged  eighteen  came  to  the  hospital  be- 
cause of  cough  and  expectoration. 

History. — The  patient  complains  of  great  weakness  and  continual 
cough  with  expectoration  of  a  dark  yellow  foul-smelling  mucous  sub- 
stance together  with  pain  along  the  ribs  on  the  right  anterior  side  of 
the  chest  when  he  coughs,  and  under  the  right  scapula  when  he  turns 
over  in  bed.    His  trouble  began  two  days  after  a  tonsillectomy  under 


DISEASES   OF    THE    CHEST   AND   SPINE  281 

ether  anesthesia  five  weeks  ago.  It  started  as  a  sharp  pain  in  the 
chest,  which  was  made  worse  by  deep  inspiration.  The  pain  is 
chiefly  in  the  right  side  and  in  front  of  the  chest  when  he  coughs 
and  some  under  the  right  shoulder  blade  when  he  turns  in  bed.  The 
cough  did  not  begin  until  about  two  weeks  after  the  first  attack  of 
pain.  He  says  the  cough  is  started  by  the  purulent  mucus  coming 
up  in  his  throat  and  he  must  cough  to  get  it  out.  About  the  time 
he  began  to  cough  he  felt  as  though  he  had  a  fever.  He  says  that  af- 
ter coughing  up  a  large  amount  of  purulent  material  he  would  be 
free  from  cough,  often  as  long  as  twenty-four  hours.  Change  of 
position  in  bed  always  brought  on  a  coughing  spell. 

Examination. — His  temperature  is  105°,  pulse  110  and  respiration 
34.  Hemoglobin  is  75  per  cent  and  there  are  17,500  leucocytes.  There 
are  increased  breath  sounds  and  dullness  below  the  fourth  rib.  When 
the  expectoration  stands  it  becomes  divided  into  three  layers,  a  foamy 
one  above,  a  clear  one  intermediate  and  a  creamy  one  below. 

Diagnosis. — The  pain  followed  by  sudden  cough  with  expectoration 
of  a  large  quantity  of  foul-smelling  pus  is  pathognomonic  of  lung 
abscess.  Added  to  these  are  the  fever,  leucocytosis,  separation  of 
the  expectorate  into  layers  on  standing  and  the  sudden  cough  with 
expectoration  when  he  changes  his  position.  The  fact  that  his  tem- 
perature is  so  high  indicates  that  drainage  is  not  so  free  as  it  should 
be. 

Treatment. — Resection  of  the  seventh  rib  in  the  postaxillary  line 
with  insertion  of  a  gauze  pack.  The  pleura  had  become  adher«it  from 
the  preceding  pleuritis  except  at  the  median  part  of  the  lung.''UThis 
made  packing  with  gauze  to  induce  adhesions  necessary  before  the  ^^- 
scess  was  sought.     The  abscess  was  entered  six  days  later. 

After-course. — The  drainage  at  first  free,  rapidly  diminished  and 
when  he  left  the  hospital  on  the  32nd  day  only  a  slight  drainage  re- 
mained. When  examined  three  months  later,  healing  was  complete 
and  he  was  free  from  any  disturbance. 

Comment. — Not  all  abscesses  require  drainage  after  they  have  once 
ruptured.  Children,  particularly,  often  heal  spontaneously.  Ab- 
scesses diagnosed  before  rupture  should  always  l3e  drained.  Abscesses 
that  do  not  heal  in  two  months  should  be  drained,  and  if  the  tem- 
perature does  not  promptly  subside  after  spontaneous  rupture,  they 
should  be  drained. 


282  CLINICAL    SURGERY    BY    CASK    HISTORIES 

CASE  4. — A  school  girl  aged  ten  was  brought  because  of  pain  in 
the  chest. 

History. — Following  an  attack  of  tonsillitis  she  siiflfered  from  sud- 
den pain  in  the  right  chest  and  had  the  general  symptoms  of  influenza 
then  epidemic.  The  pain  in  the  side  resembled  a  pleurisy  and  con- 
solidation was  never  pronounced.  The  temperature  rose  and  con- 
tinued unabated  until  the  time  of  operation,  now  three  weeks  ago. 

Examination. — There  is  dullness  in  the  lower  right  chest,  but  not 
the  marked  flatness  of  exudate.  There  are  breath  sounds  over  the 
larger  part  of  the  dull  area.  The  dull  area  extends  higher  in  front 
than  in  the  back  and  does  not  move  with  a  change  in  position. 

Diagnosis. — The  manner  of  onset  suggested  a  pleurisy  and  the 
course  of  the  fever  suggests  its  transformation  into  an  empyema. 
The  marked  respiratory  sounds  are  not  usual  in  fluid  accumulations, 
though  this  is  inconstant. 

Treatment. — Kib  resection  and  drainage. 

PatJiology. — The  pleural  cavity  was  free  but  obliterated.  A  needle 
passed  2  cm.  into  the  lung  secured  pus.  A  drainage  tube  allowed 
a  considerable  amount  of  pus  to  escape.  The  abscess  cavity  seemed 
unusually  well  defined  but  no  necrotic  lung  was  in  evidence. 

After-course. — Recover}^  was  complete  in  six  months. 

Comment. — This  case  suggests  the  possibility  of  a  direct  metastasis 
from  the  tonsils  and  the  possibility  that  lung  abscess  following  tonsil- 
lectomy need  not  be  due  to  a  faulty  technic. 

CASJS  5. — A  baby  aged  fifteen  months  v^^as  brought  to  the  hospital 
becft»se  of  abdominal  distention,  constipation,  and  general  wasting 
apray. 

History. — Two  months  ago  the  baby  had  the  German  measles  and 
a  week  later  she  developed  bronchopneumonia  with  a  rise  of  tem- 
perature to  104°.  After  a  couple  of  weeks  temperature  became  nor- 
mal in  the  mornings  but  went  up  in  the  evenings  usually  to  about 
102°.  About  ]\Iay  1  the  doctor  pronounced  the  case  empyema  because 
the  child  had  gradually  weakened  and  wasted  away.  For  the  last 
tw^o  weeks  she  has  had  abdominal  distention  and  obstinate  consti- 
pation. 

Examination. — There  is  flatness  of  the  entire  right  side  of  the 
chest.  Absent  vocal  fremitis  on  this  side  and  the  breath  sounds  are 
scarcely  audible.     The  temperature  is  103°. 


DISEASES    OF    THE    CHEST    AND    SPINE  283; 

Diagnosis. — The  history  of  measles  and  bronchopneumonia  with 
continued  temperature  and  flatness  of  the  chest  leaves  but  little 
doubt  but  that  we  have  to  do  with  an  empyema. 

Treatment. — The  seventh  rib  was  resected  and  half  a  pint  of  pus 
escaped. 

After-course. — The  temperature  came  to  normal  in  a  few  days  and 
the  child  began  rapidly  to  gain  weight. 

After  several  months  of  well-being,  the  child  began  three  or  four 
days  ago  to  run  a  temperature.  It  went  as  high  as  104°  several 
evenings.  She  vomited  a  few  times,  and  became  very  much  distended 
and  had  five  or  six  watery  green  stools  daily.  She  had  been  practi- 
cally on  an  adult  diet.  On  admission  the  temperature  was  100.5°, 
the  pulse  120  and  the  respirations  were  22.  There  was  no  flatness 
on  percussion  on  either  side  of  the  chest,  breath  sounds  w^ere  normal 
through  both  lungs  and  there  was  no  decrease  in  voice  sounds  in 
either  lung.  The  wound  in  the  chest  wall  from  the  rib  resection 
and  drainage  of  empyema  had  entirely  healed.  Acute  gastroenteri- 
tis was  diagnosticated.  Appropriate  treatment  for  this  complaint 
was  instituted  and  the  recovery  was  prompt  and  lasting. 

Comment. — The  patient  was  returned  for  a  renewed  drainage  of 
the  chest.  The  temperature  and  distention  of  the  abdomen  were  sim- 
ilar in  the  two  admissions,  but  the  physical  findings  were  wholly 
different.  Yet  the  family  doctor  was  entirely  correct  in  his  surmise 
for  a  recently  drained  empyema  that  develops  temperature  most 
likely  has  retained  pus. 

CASE  6. — A  school  girl  of  seven  was  brought  to  the  hospital  be- 
cause of  continued  fever  and  loss  of  weight. 

History. — Thirteen  months  before  while  at  play,  she  swallowed  a 
pin.  It  was  a  steel  pin  with  a  round  head,  and  about  an  inch  and 
a  quarter  in  length.  It  gave  her  no  trouble  at  the  time.  Five  or 
six  months  later  she  gradually  developed  a  cough  which  has  con- 
tinued and  grown  worse.  She  had  weak  sj^ells  while  at  play  and 
had  to  be  carried  in.  Two  months  before  entering  the  hospital  the 
symptoms  increased.  The  cough  gradually  became  worse,  especially 
at  night.  Some  sputum  was  raised.  Starting  from  the  back  there  was 
pain  which  radiated  to  the  epigastrium  and  left  side.  The  tempera- 
tnvo  ^^rpc:.  102-10^°.  Ther^  was  loss  of  aDpetite  and  frequent  attacks 
of  vomiting.  The  left  shoulder  drooped  when  she  stood  straight. 
SDutum  examined  ^was  negative. 


284 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


Examination. — The  patient  is  greatly  emaciated  and  very  weak. 
Temperature  104°,  pulse  144,  respiration  40.  Physical  examination 
of  the  chest  showed  dullness,  decreased  breath  sounds  and  decreased 
fremitus  over  the  entire  posterior  left  side.  The  x-ray  showed  a 
shadow  over  the  entire  left  chest,  indicating  fluid  in  the  pleural  cav- 
ity, and  a  very  definite  shadow  of  a  pin,  head  downward,  about  an 
inch  or  an  inch  and  a  half  above  the  diaphragm,  a  quarter  of  an  inch 


Fig.   140. — Pin  in  left  bronchus. 


DISEASES    OF    THE    CHEST   AND   SPINE  285 

to  the  left  of,  and  one  inch  anterior  to,  the  bodies  of  the  vertebrae,  the 
point  of  the  pin  pointing  slightly  toward  the  midline  (Fig.  140). 

Diagnosis. — Empyema  or  lung  abscess  from  a  foreign  body.  It  is 
most  likely  to  be  an  empyema  because  of  the  extent  of  dullness.  It 
would  be  very  unusual  for  a  lung  abscess  to  occupy  so  much  space. 

Treatment. — -A  rib  was  resected  and  the  chest  drained.  The  tem- 
perature promptly  dropped  and  the  patient  soon  began  to  gain 
strength. 

After-course. — She  left  the  hospital  in  fifteen  days  with  the  chest 
still  draining,  and  returned  for  observation  and  dressings  occasionally. 
A  month  after  leaving  the  hospital  she  had  a  coughing  spell  and 
coughed  up  a  piece  of  the  pin  a  little  more  than  %  inch  in  length. 
The  point  was  quite  sharp  yet,  but  the  other  end  where  it  was  broken 
off  was  very  much  corroded.  On  December  13  when  the  patient 
was  last  seen,  she  was  feeling  perfectly  well,  she  had  gained  weight 
from  26  to  46  pounds,  and  the  chest  was  normal.  X-ray  of  the  chest 
at  this  time  showed  no  foreign  body. 

Comment. — An  abscess  evidently  formed  about  the  pin  and  later 
ruptured  into  the  pleural  cavity. 

CASE  7. — A  farmer  aged  twenty -four  came  to  the  hospital  because 
of  cough  and  loss  of  strength. 

History. — The  patient  was  perfectly  well  up  to  six  months  ago. 
While  riding  a  cultivator  he  had  a  sharp  pain  in  the  epigastrium^ — - 
he  thinks  also  that  there  was  some  tenderness.  The  pain  was  con- 
tinuous and  gradually  increased  in  severity.  He  consulted  a  physician 
four  or  five  hours  after  the  onset,  took  some  medicine,  and  the  pain 
left  about  ten  hours  later,  leaving  soreness  in  the  epigastrium  and 
weakness  for  two  or  three  days.  He  had  fever,  100°  or  100.5°.  He 
was  quite  well  for  two  weeks,  when  he  became  chilled  during  a  ride 
and  developed  tonsillitis,  lasting  two  or  three  days.  After  the  ton- 
sillitis subsided  he  began  to  have  fever  which  persisted.  Never  had 
chills.  He  commenced  coughing  at  this  time  and  expectoration  began 
a  day  later. 

Examination. — The  patient  has  a  distinctly  hectic  appearance.  The 
respiration  is  rapid  and  somewhat  labored.  The  left  lung  shows  no 
abnormalities.  The  right  gives  limited  dullness  over  the  5th  to  7th 
ribs  behind,  with  lessened  resonance  above  and  below.  There  are 
some  lessened  heart  sounds  over  the  dull  area.    A  diagnosis  of  lung 


286 


n.lXICAL    SURGERY    BY    CASE    HISTORIES 


abscess  was  made  and  preparations  were  made  to  drain  it.  During 
the  night  he  was  seized  with  a  fit  of  coughing  and  spat  up  350  c.c. 
of  pus.  This  on  standing  separated  into  three  distinct  planes  (Fig. 
141). 

Diagnosis. — The  early  history  of  this  case  is  confusing.  The  source 
of  the  epigastric  pain  was  not  determined.  There  was  no  history  to 
aid.     It  had  the  sudden  onset  of  an  ai)peiulieeal  pain.     In  view  of 


Fig.  141. — Sputum  from  a  case  of  lung  abscess  showing  separation  of  sputum  into  tliree  layers. 


DISEASES   OF    THE    CHEST   AND    SPINE  287 

the  subsequent  history,  it  seems  quite  possible  that  it  was  pleural  in 
origin.  The  continuous  fever,  cough,  and  general  weakness  gave 
rise  to  a  diagnosis  of  typhoid  fever  and  acute  tuberculosis  by  several 
doctors  who  were  consulted.  The  localized  dullness,  the  irritating 
cough,  and  rapid  respiration  centered  the  attention  on  this  region 
and  the  temperature  and  leucocytosis  found  suggested  suppuration 
rather  than  tuberculosis.  After  the  profuse  expectoration  appeared, 
further  speculation  was  unnecessary. 

Treatment. — Since  the  abscess  had  ruptured  before  drainage  could 
be  effected,  he  was  sent  home  to  recuperate  and  to  await  Nature's 
efforts  to  effect  a  cure. 

After-course. — The  patient  improved  in  general  health  and  the 
expectoration  gradually  lessened.  Though  signs  of  consolidation  re- 
mained for  many  months,  the  recovery  ultimately  was  complete. 

Comments. — The  source  of  infection  is  obscure.  If  the  epigastric 
pain  was  appendiceal  in  origin,  this  may  have  furnished  the  focus. 
Should  there  have  been  a  pneumonia,  the  source  was  equally  plain. 
The  organism  was  predominantly  streptococcic.  Most  likely  the 
tonsil  attack  was  linked  in  the  chain  of  etiologic  factors.  I  have  seen 
tonsillitis  and  appendicitis  associated,  as  have  all  surgeons,  and  I 
have  seen  lung  abscess  follow  each,  and  possibly  as  in  this  case 
following  both. 

CASE  8. — A  school  girl  was  brought  to  the  hospital  because  of 
complications  following  pneumonia. 

History. — The  patient  had  influenza  four  months  ago.  In  ten  days 
she  had  a  temperature  of  105°  and  pneumonia  was  diagnosticated. 
Both  lungs  were  said  to  have  been  involved.  In  a  week  the  temperature 
came  down  to  101-102°.  A  week  following  the  temperature 
Avas  subnormal  in  the  morning  and  usually  reached  103°  in  the 
afternoon.  This  state  continued  for  six  to  eight  weeks.  Four  weeks 
ago  she  had  a  violent  coughing  spell  at  the  termination  of  which 
she  spat  up  half  a  pint  of  pure  pus.  The  temperature  remained 
around  100°  to  101°  for  a  week  or  two.  Following  this  the  tempera- 
ture began  to  rise  again  until  she  coughed  up  a  large  quantity  of  pus, 
after  which  the  temperature  again  went  down.  It  began  to  rise  again 
in  a  few  days,  and  on  entering  the  hospital,  she  had  pulse  130,  tem- 
perature 102.5°,  respiration  40. 

Examination. — The   patient    is   anemic   and    emaciated.      The    left 


288  CLINICAL   SURGERY   BY    CASE   HISTORIES 

side  of  the  chest  is  large  and  motionless,  while  the  patient  labors 
diligently  in  her  breathing,  but  without  cyanosis.  The  whole  lower 
portion  of  the  chest  is  flat  and  the  vocal  fremitus  is  absent.  The 
x-ray  showed  the  whole  lower  chest  to  be  occupied  by  a  shadow. 

Diagnosis. — The  history  of  the  expectoration  of  a  large  amount  of 
pus  after  violent  coughing  was  evidence  that  an  accumulation  of  pus 
Avas  present  in  the  chest.  The  sole  problem  w^as  whether  an  empy- 
ema had  reached  a  bronchus  or  whether  the  process  was  primarily 
a  lung  abscess.  The  complete  flatness  over  the  entire  area  spoke  for 
a  primary  empyema  Avhile  the  repeated  periods  of  expectoration 
followed  by  a  drop  in  the  temperature  spoke  for  a  primary  lung 
abscess.    At  most  the  question  was  purely  acadeinic. 

Treatment. — A  portion  of  the  9th  rib  in  the  axillary  line  was  re- 
moved. The  lung  was  adherent  to  the  parietal  pleura.  Since  the 
opening  in  the  chest  was  so  low,  it  was  thought  that  the  empyema 
might  be  higher.  After  separating  the  pleurge  for  the  distance  of  an 
inch  the  fluctuating  abscess  within  the  lung  could  be  felt.  A  hemo- 
stat  was  pushed  into  the  lung  and  a  huge  cavitj'  opened.  The  depth 
of  the  cavity  could  not  be  measured  by  the  finger.  A  large  rubber 
tube  was  placed  in  the  cavity  and  an  abundant  dressing  applied  over 
the  chest. 

After-course. — The  temperature  reached  normal  in  two  days  and 
remained  so  for  a  week,  when  it  suddenly  went  to  104°  accompanied 
by  rapid  respiration.  Investigation  showed  the  drainage  to  have 
become  checked.  The  reestablishment  of  the  drainage  was  followed 
by  a  prompt  and  permanent  drop  in  the  temperature.  She  was  al- 
lowed to  go  home  on  the  fifteenth  day.  She  returned  at  intervals 
of  three  weeks  Avhen  the  tube  was  shortened  each  time.  The  tube 
was  left  out  at  the  ninth  week.  The  resonance  had  returned  and 
the  breath  sounds  were  returning.  After  four  months  there  was 
little  save  the  scar  remaining. 

Comment.— in  draining  lung  abscesses,  as  in  any  other  abscess 
drainage  should  be  efficient  and  should  reach  near  the  deepest  point 
of  the  abscess,  lest  a  collapse  of  the  walls  separate  off  a  part  from 
the  drainage  tube.  The  drainage  tube  should  be  allowed  to  remain 
so  long  as  the  drainage  is  free.  At  the  same  time  the  fact  must  not 
be  overlooked  that  the  tube  itself  will  be  responsible  for  some  dis- 
charge. A  good  rule  is  that  whenever  the  abscess  has  closed  down  to 
the  tip  of  the  tube  it  should  be  shortened. 


DISEASES    OF    THE    CHEST    AND    SPIXE  289 

CASE  9. — A  real  estate  dealer  aged  fifty-six  came  because  of  stom- 
ach trouble,  pain  in  his  chest  and  difficulty  in  breathing. 

History. — Ten  years  ago  he  began  to  be  troubled  with  gas  on  his 
stomach.  His  doctors  diagnosed  gallstones.  Every  month  or  so  he 
would  be  sick  at  his  stomach  and  he  felt  as  though  everytliing  was 
turning  over.  Four  years  ago  he  had  a  severe  spell ;  it  came  on 
suddenly  while  he  was  milking.  He  was  scarcely  able  to  get  to 
the  house.  The  doctor  remained  with  him  all  night.  The  pain  stayed 
in  the  pit  of  the  stomach,  it  did  not  radiate  and  there  was  none 
in  the  back.  A  brown  streak  developed  on  his  tongue.  The  doctor 
said  he  just  escaped  typhoid.  He  was  nauseated  and  vomited  at 
intervals  for  24  hours.  His  most  severe  pain  was  over  the  heart. 
He  had  fever  and  was  in  bed  two  weeks.  Since  then  he  has  had 
brief  spells  of  nausea  and  pain  in  the  region  of  the  heart  or  stomach. 
They  are  not  related  to  the  meal  time.  He  has  some  generalized 
headache  at  this  time.  He  has  had  a  slight  cough  at  times.  His 
bowels  are  very  irregular,  diarrhea  alternating  with  constipation. 
He  has  had  bladder  irritation  at  intervals.  Three  years  ago  it  was 
quite  severe  for  a  day.  Six  or  seven  months  ago  he  noticed  a  mole 
on  his  right  shoulder.  Soon  after  it  began  suddenly  to  grow.  He 
thinks  he  must  have  bruised  it  because  it  seemed  inflamed.  Three 
months  ago  a  doctor  snipped  off  the  projecting  part  with  a  pair  of 
scissors.  It  began  to  grow  again  and  now  is  larger  than  ever.  The 
patient  had  various  diseases  of  childhood  and  malaria  many  years 
ago.  He  had  chills  and  fever  at  intervals  for  a  year  and  a  half.  He 
was  cured  by  change  of  climate  and  quinine. 

Examination. — The  patient  makes  it  clear  that  he  must  have  relief 
and  that  he  is  willing  to  do  whatever  is  necessary  to  secure  this  end. 
He  has  an  apprehensive  look  and  gives  evidence  of  loss  of  weight 
and  strength.  His  muscles  are  flabby,  the  skin  inelastic.  He  in- 
dicates the  site  of  his  severe  pain  four  years  ago,  as  just  below  and 
to  the  left  of  his  xiphoid  process.  His  abdomen  is  a  little  distended, 
soft  and  slightly  tender  at  the  upper  part.  The  edge  of  the  liver  is 
just  palpable.  Heart  and  lungs  are  negative  save  for  a  slight  loss  of 
resonance  in  the  right  lower  lobe  behind.  The  lower  lung  border  is 
negative.  The  tumor  on  the  shoulder  is  half  an  inch  in  diameter  and 
half  as  high.  It  is  deep  blue-black  in  color  and  there  are  many 
dilated  vessels  visible  in  the  skin  about  it  (Fig.  142).  This  growth 
was   removed.     It   is   a   melanoma.      The   advancing   border   of   the 


290 


CLINICAL   STTRGERY   BY    CASE    HISTORIES 


growth  shows  large  deeply  staining  cells  which  contain  pigment.  The 
patient's  urine  is  negative,  the  renal  output  50  c.c.  the  first  hour, 
25  c.c.  the  next.  His  blood  shows  90  per  cent  Hg.,  R.b.c.  4,400,000, 
W.b.c.  26,000,  of  which  90  per  cent  are  polynuclears.  The  tempera- 
ture is  98.4°,  pulse  70,  respiration  18. 

Diagnosis. — The  history  suggests  a  primary  stomach  trouble  proba- 


Fig.    142. — Irritated    melanoma    nf    tlu-    bhuuliii  r. 


bly  an  ulcer  which  likely  perforated  four  years  ago  when  he  had 
a  sudden  epigastric  pain  and  could  hardly  get  to  the  house.  His  con- 
dition must  have  been  somewhat  serious  or  his  doctor  would  not 
have  stayed  thirty-six  hours.  He  probably  was  not  much  of  a  doctor 
or  he  would  not  have  done  so  anyway.  There  must  have  been  some 
toxic  symptoms  because  he  was  in  bed  two  weeks  and  got  a  brown 
streak  down  his  tongue.     He  has  had  attacks  since  which  would  in- 


DISEASES    OF    THE    CHEST   AND    SPINE  291 

dicate  the  possibility  of  a  perigastric  adhesion.  There  is  evidently 
something  that  has  been  added  in  the  past  few  months  that  has  pro- 
duced a  rapid  decline.  The  leucocytosis  of  26,000  is  unexpected  and 
impressive.  One  thinks  of  a  perigastric  abscess.  His  appearance  is 
not  that  of  sepsis,  there  is  not  sufficient  epigastric  tenderness  or  rigid- 
ity to  warrant  such  an  assumption.  Furthermore,  the  pulse  is  nor- 
mal in  rate  and  volume,  and  the  temperature  is  undisturbed.  An 
abscess  capable  of  producing  such  leucocytosis  would  scarcely  allow 
this.  The  melanoma  of  the  shoulder  stands  out  as  a  source  of  trouble. 
Whenever  a  melanotic  tumor  is  present  or  was  present  it  should  be 
regarded  as  guilty  until  the  contrary  can  be  proved.  A  melanotic  me- 
tastasis is  entirely  capable  of  doing  all  of  which  the  patient  has  com- 
plained. The  x-ray,  while  not  diagnostic  of  an  intrapulmonary  le- 
sion, is  compatible  with  such  an  assumption.  The  probable  diagnosis 
is  melanotic  metastasis  probably  in  the  right  lung. 

Treatment. — Expectant. 

After-course. — His  condition  did  not  improve  by  rest  in  bed.  At 
the  end  of  a  week  dullness  was  definite  in  both  lungs.  On  the  tenth 
day  5  c.c.  of  clear,  thin  fluid  was  aspirated  from  the  left  chest.  A 
motile  bacillus  was  cultured  from  this.  The  laboratory  man  regarded 
this  as  a  contamination,  thus  making  the  ox)inion  unanimous.  On 
the  twelfth  day  there  was  dullness  on  the  right  side  extending  up  as 
high  as  the  angle  of  the  scapula.  There  was  no  flatness  anywhere. 
While  the  respiratory  sounds  were  diminished  over  this  area,  they  were 
present.  The  same  is  true  of  vocal  fremitus.  At  this  time  an  enlarged 
gland  was  noticed  in  the  right  axilla.  This  gland  rapidly  enlarged 
and  attained  the  size  of  a  walnut.  It  was  hard,  encapsulated,  some- 
what bosselated,  and  only  slightly  sensitive  to  ]pressure.  The  patient 
developed  a  dyspnea  with  distress  not  deflnitely  deflned,  and  in  two 
days  he  died.    Autopsy  was  refused. 

Comment. — There  seems  but  little  doubt  that  the  terminal  disease 
was  a  melanotic  metastasis.  The  high  leucocytosis  is  not  unusual  in 
this  condition. 

DISEASES  OF  THE  SPINE 

Congenital  deformities  of  the  spine  offer  no  difficulties,  and  Pott's 
disease  is  well  learned  in  school,  but  the  various  inflammatory  dis- 
eases of  the  spine  are  usually  overlooked.    The  lesions  of  the  cord  are 


292 


CLIN'ICAL    F^l-RGERY    BY    CASE    HISTORIES 


well  understood  by  the  neurologist,  but  inflammations  must  be  found 
by  the  surgeon  himself  if  he  is  not  to  be  led  into  useless  operating. 

CASE  1. — A  baby  three  and  a  half  months  was  brought  in  because 
of  a  tumor  on  the  back  of  its  neck. 

History. — The  baby  was  born  with  its  tumor.  It  seems  otherwise 
well  and  has  nursed  at  the  breast.  There  is  another  child  two  and 
a  half  years  old  who  is  normal  in  every  way.  The  mother  is  fleshy, 
of  almost  myxedematous  habitus. 

Exoimination. — The  l)aby  seems  a  fine  physical  specimen  save  for 


Fig.    143. — Spina   bifida    of   the   cervical    region. 

the  tumor  on  its  neck.  This  is  as  large  as  an  orange,  soft,  and  com- 
pressible. The  surface  is  reddish  and  shows  a  large  number  of  ves- 
sels. The  tumor  can  be  seen  through  this  area  to  be  made  up  of  a 
straw-colored  fluid.  There  is  a  spinal  defect  representing  about  the 
fifth  and  sixth  cervical  arches  (Fig.  143).  The  large  fontanelle  is 
somcAvhat  bulging  and  the  forehead  unduly  prominent.  All  the 
extremities  seem  capable  of  normal  movement. 

Diagnosis. — Xo  strands  or  bunches  can  be  made  out  in  the  wall  of 
the  sac.  This,  together  with  the  fact  that  all  the  extremities  are  ac- 
tive, makes  it  likely  that  it  is  a  pure  meningocele.  The  tenseness  of 
the  fontanelle  and  the  size  and  shape  of  the  head  make  it  likely  that 
a  certain  degree  of  hydrocephalus  is  present. 


DISEASES    OF    THE    CHEST    AXD    SPIXE  293 

Treatment. — An  elliptical  incision  was  made  near  the  base  of  the 
mass  and  the  flaps  deflected.  An  attempt  was  made  to  transfix  the 
dura  with  a  catgut  suture,  but  it  was  torn  into  and  it  had  to  be  united 
with  a  sort  of  mattress  Lembert  followed  by  a  whipped  overstitch. 
The  skin  was  united  by  a  mattress  stitch. 

Pathology. — The  portion  cf  the  membrane  removed  showed  no  nerve 
structures. 

After-course. — The  baby  did  well,  save  that  in  spite  of  collodion 
dressings,  large  quantities  of  cerebrospinal  fluid  escaped.  This  checked 
materially  in  a  week,  and  since  the  wound  was  without  reaction, 
the  parents  were  allowed  to  take  the  child  home.  Her  doctor  vri'ote 
that  four  daj's  following  the  return  home,  the  baby  became  restless, 
the  fontanelles  sunken  and  a  bluish  discoloration  presented  about  the 
wound.    The  next  day  it  died. 

Comment. — It  is  likely  that  a  meningitis  followed  the  drainage 
tract.  Greater  care  might  have  prevented  a  leaking  wound.  At  least 
once  the  leak  occurred  the  desire  of  the  parents  to  return  home 
should  have  been  combated  until  the  leak  should  have  ceased.  Cessa- 
tion of  such  leaks  is  often  exceedingly  difficult  to  bring  about,  many 
weeks  being  often  required  in  the  process.  AVhat  the  ultimate  out- 
come would  have  been  had  the  operation  been  successful  is  difficult 
to  say.  Usually  there  is  a  progressively  increasing  hydrocephalus. 
Possibly  it  would  be  better  not  to  operate  these  patients  at  all. 

CASE  2. — A  child  nine  days  old  was  brought  to  me  because  of  an 
ulcer  on  its  back. 

History. — At  birth  it  was  noticed  there  was  a  tumor  in  the  middle 
of  the  baby's  back.  Immediately  after  birth  it  was  not  noted  that 
there  was  any  discharge  from  the  tumor,  but  for  a  number  of  days 
any  dressing  that  is  applied  quickly  becomes  saturated  by  a  clear 
fluid.  The  child  nurses  vigorously,  and  moves  its  arms  freely,  but 
has  not  been  observed  to  move  its  feet.  The  mother  has  nine  other 
children,  in  none  of  whom  is  there  any  defect. 

Examination. — In  the  dorsolumbar  region  is  an  ovoid  elevation  2 
em.  high.  It  is  10  by  1-1  cm.  in  size  (Fig.  1-11:1.  The  outer  border 
is  covered  with  normal  skin  continuous  with  the  skin  of  the  back.  In- 
side of  this  border  of  normal  skin  is  a  thin,  reddish  membrane-like 
structure  and  covering  the  center  is  a  thin,  veil-like  membrane  which 
has  a  defect  at  one  point  from  which  a  thin  clear  fluid  escapes.     Be- 


294  CLINICAL    SURGERY    BY    CASE    HISTORIES 

neath  the  thin  membrane  are  numerous  Avhitish  indefinitely  formed 
strands.  The  baby  moves  its  hands,  but  can  not  be  excited  to  move 
the  legs. 

Diagnosis. — The  fine  pellicle-like  membrane  above  noted  evidently 
represents  the  pia,  and  the  ill-formed  bundles,  a  portion  of  the  spinal 
cord.  The  condition  then  must  be  designated  a  meningomyelocele. 
Since  no  movements  of  the  legs  have  been  noticed  neither  can  any  be 
elicited,  it  seems  fair  to  assume  that  the  sacral  plexus  is  destroyed. 


Fig.    144, — Spina  bifida. 

Treatment. — ^None  was  advised  save  the  application  of  aseptic 
dressings. 

After-course. — The  patient  died  in  ten  days. 

Comment. — No  sort  of  treatment  can  produce  motion  in  the  legs 
in  such  cases.  The  most  that  can  be  hoped  for  would  be  the  pres- 
ervation of  a  child  whose  legs  are  useless  and  whose  bladder  and  rec- 
tum are  beyond  control.  Whether  or  not  professional  duty  compels 
one  to  make  this  effort  is  a  question  each  must  decide  for  himself. 
If  there  is  a  defect  in  the  control  of  the  bladder,  death  usually  fol- 
lows from  this  cause.  If  the  sac  has  ruptured,  death  usually  follows 
in  a  week  or  two;  if  unruptured,  a  repair  of  the  defect  is  usually  pos- 
sil)le. 

CASE  3. — A  girl  aged  three  years  was  brought  to  the  hospital 
because  of  a  tumor  on  the  low^er  part  of  her  back. 

History. — The  child  was  normal  at  Inrth  in  every  waA'  save  for  the 
tumor  over  the  lower  part  of  the  back.     She  learned  to  walk  at  the 


DISEASES   OF    THE    CHEST   AND    SPINE  295 

normal  period.  There  was  no  disturbance  of  the  rectum  or  bladder. 
There  are  four  older  children  in  this  famih^,  none  of  whom  have  any 
developmental  anomaly.  The  period  of  gestation  the  mother  states 
was  not  marked  by  any  unusual  occurrence.  She  also  states  that 
she  had  no  menstrual  disturbance  prior  to  conception. 

Examination. — A  tumor  the  size  of  an  orange  occupies  the  lumbo- 


Fig.    145. —  Spina   bilida   uf   the   sacral   region. 

sacral  junction  (Fig.  145).  The  skin  about  the  base  is  normal,  but 
toward  its  surface  is  thinned  and  attached  to  the  underlying  tis- 
sue, but  is  not  reddened.  It  is  fluctuating  and  transmits  light.  The 
child  walks  normally  and  there  is  no  abnormality  of  formation  or 
function  of  the  legs. 

Diagnosis. — "When  there  are  no  disturbances  in  the  legs  usually 
the  tumor  is  composed  of  dilated  spinal  meninges,   though  some- 


296  CLINICAL    SURGERY    BY    CASE    HISTORIES 

times  ill  these  cases  the  nerves  may  be  united  in  the  wall  of  the 
tumor.  Usually  in  myelocele  the  legs  are  paralyzed.  From  terato- 
mas this  may  be  differentiated  because  of  the  transmitted  light,  the 
evident  absence  of  solid  mass  and  in  a  measure  by  the  location. 
Teratoid  tumors  are  usually  located  at  the  extreme  terminal  por- 
tion of  the  spinal  column. 

Operation. — A  sufficient  area  of  skin  was  preserved  below  an  ellip- 
tical incision.  The  meninges  and  soft  parts  were  carefully  dis.sected 
loose  to  the  base.  The  redundant  portion  was  removed  above  a 
pair  of  intestinal  clamps.  After  inspection  of  the  contents  of  the 
sac,  this  membrane  was  united  side  to  side  by  a  shoemaker's  stitch, 
the  subcutaneous  tissue  and  skin  were  closed  by  separate  layers.  The 
wound  was  .sealed  witli  a  collodion  dressing.  The  spinal  cord  and 
Cauda  lay  in  the  depth  of  the  cyst,   apparently  unharmed. 

Pathology. — The  cyst  wall  removed  was  composed  entirely  of  fi- 
l)rous  tissue.  The  fibers  were  collected  in  irregularly  placed  bundles  in 
some  places  which  gave  them  the  appearance  of  nerves.  No  nerve 
elements  could  be  demonstrated. 

After-course. — Recovery  was  uneventful  and  the  child  developed 
normally. 

Comment. — Such  simple  cases  unfortunately  are  seldom  encoun- 
tered. Usually  the  cord  structures  are  involved  in  the  sac  and  despite 
every  caution  are  subject  to  injury.  The  practice  of  attempting  to 
cover  the  defect  by  bone  or  periosteal  transplants  is  unnecessary. 

After  the  bulging  sac  is  removed  the  surrounding  structures 
tend  to  cover  the  defect  more  and  more.  The  idea  of  closing  the 
gap  is  theoretically  sound,  but  it  prolongs  the  operation  and  extends 
the  traumatized  field.  In  children  who  have  reached  the  age  of  dis- 
cretion, a  simple  collodion  dressing  suffices.  In  very  young  children 
a  rubber  covering  should  be  added.  In  addition  a  relay  of  nurses 
should  keep  the  child  in  a  sitting  position  for  a  week  in  order  that 
excreta  may  gravitate  downward  and  not  jeopardize  the  dressing  by 
creeping  along  the  sacral  spine.  Infection  is  the  one  danger,  and 
this  continuation  of  precautions  is  the  on\j  effective  means  of  con- 
trolling it  that  I  have  found. 

CASE  4. — A  farmer  age  twenty-nine  came  in  for  tonsil  removal. 

History. — From  the  day  after  the  operation  the  temperature  went 
up  to  103°  and  remained  between  100.5°   and  104.5"  for  nine  days. 


DISEASES    OF    THE    CHEST    AND    SPINE  297 

He  complained  of  a  very  severe  pain  in  the  cervical  vertebra  during 
the  whole  time.  The  temperature  gradually  came  to  normal  and 
the  pain  lasted  some  time  after  the  temperature  became  normal, 
gradually  passing  away. 

The  highest  blood  count  during  the  fever  showed  a  leucocytosis  of 
only  10,800.  The  lungs  were  negative,  urine  negative,  and  the  whole 
physical  findings  were  negative  with  the  exception  of  a  rigidity  of 
the  neck  and  pain  on  movement  of  the  head  from  side  to  side.  He  was 
troubled  with  severe  headaches  at  intervals. 

Brain  abscess,  lung  abscess  and  generalized  infection  of  the  tissues 
of  the  neck  were  thought  of,  but  a  diagnosis  of  neither  could  be 
made. 

The  trouble  seemed  to  be  an  acute  spondylitis  involving  the  cervi- 
cal vertebra. 

CASE  5. — A  fanner  aged  forty-three  was  brought  to  the  hospital 
because  of  pain  in  the  back. 

History. — The  patient  has  always  lived  on  a  farm  and  for  five  years 
prior  to  his  illness  worked  in  a  coal  mine  during  the  winter  months. 
Eight  years  ago  he  began  to  have  pain  in  the  hips.  During  the 
winter  he  had  a  severe  pain  which  extended  doAvii  the  back  of  the 
right  leg.  This  was  diagnosed  as  sciatica.  With  rest  in  bed  and 
general  treatment  this  gradually  improved,  and  by  spring  it  had 
entirely  disappeared  never  to  return.  Three  years  later  he  began 
to  have  pain  in  the  chest,  shoulders,  and  neck.  This  was  at  one 
time  so  severe  that  he  could  not  turn  his  head.  These  pains  have 
continued,  and  now  he  is  unable  to  turn  his  head,  even  when  he 
bears  the  pain.  When  he  lies  in  bed  for  a  fcAV  days  with  the  head 
and  neck  Avell  supported  the  pain  disappears.  His  general  health 
has  always  been  good,  except  for  rheumatism  as  a  boy  and  recurrent 
attacks  of  tonsillitis.  Recentl}^  he  has  lost  in  weight  and  his  appe- 
tite is  poor. 

Examination. — The  patient  lies  in  bed  with  the  neck  slightly 
flexed  on  his  chest.  When  asked  to  look  from  side  to  side  he  ro- 
tates the  eyes  as  far  as  possible  and  supplements  this  when  neces- 
sary by  turning  the  entire  body.  When  the  examiner  attempts 
to  rotate  the  head  he  exclaims  from  pain  and  complains  that  the 
muscles  are  caused  to  cramp  painfully.  He  thinks  this  is  the  cause 
of  his  inabilitv  to  rotate  his  head.    To  the  sensation  of  the  examiner 


298 


CLINICAL    SURGERY   BY    CASE   HISTORIES 


it  is  evident  that  the  limitatiou  is  due  to  bony  changes.  The 
head  can  be  flexed  slightly  more  on  the  chest  until  it  encounters 
bony  resistance.  Attempts  to  flex  it  beyond  a  certain  point  are 
met  at  once  by  bony  resistance.  He  is  unable  to  flex  or  extend  the 
lumbar  region  to  any  degree.  The  right  thigh  can  be  flexed  to  an 
angle  of  60  degrees  only,  when  it  is  stopped  bj^  bony  resistance. 
When  attempts  are  made  to  flex  it  beyond  this  point,  it  is  noted 
that  the  lumbar  spines  are  completely  ankylosed.  The  left  thigh 
flexes  in  a  normal  degree.    He  has  noticed  a  gradual  impairment  of 


Fig.    146. — Spondylitis. 


vision.    There  is  no  demonstrable  changes  in  sensation  and  no  pain- 
ful areas. 

Dkignosis. — His  preliminary  pains  in  the  hips  were  due  obviously 
to  an  arthritis  as  is  evidenced  by  the  bony  limitation  of  motion 
still  manifest.  Recovery  may  be  ascribed  to  the  organization  of  the 
arthritic  process.  The  sciatic  pain  was  an  extension  of  irritation 
from  the  capsular  involvement.  The  later  pains  in  the  chest  and 
neck  no  doubt  were  due  to  a  spondylitic  process.  AVhat  remains 
is  a  complete  ankylosis  of  portions  of  the  vertebral  column  and  a 
still  existing  spond^'litis  in  other  segments.  The  general  deteriora- 
tion in  his  health  must  be  secondary  to  this.  The  whole  process  may 
be  defined  as  an  ossifying  spondylitis. 


DISEASES    OF    THE    CHEST    AXD    SPINE  299 

Treatment. — He  was  given  guaiacol  internally  as  suggested  by 
MacXanghten  Jones.  Heat  was  nsecl  along  the  spine.  Neither  of 
these  measures  modified  the  disease  in  the  least. 

After-course. — The  pains  lessened,  but  the  general  condition  eon- 
tinned  to  decline.  No  obvions  cause  could  be  assigned.  He  died 
in  nine  months  after  the  first  examination  without  there  being  discov- 
erable any  lesion  of  any  organ. 

PotJioJogy. — The  upper  dorsal  vertebra  were  completely  ankylosed 
(Fig.  146).  The  lumbar  and  cervical  regions  were  less  completely  af- 
fected, but  the  changes  were  sufficient  to  make  a  completely  fixed 
column.  The  intervertebral  ossifying  process  seems  to  begin  in  the 
ligaments  and  aifects  the  joint  surfaces  and  the  intervertebral  discs 
secondarily.  This  seems  to  confirm  the  x-ray  findings  in  the  milder 
cases  that  recover.  At  autopsy  no  lesion  was  found  responsible  for 
death,  save  a  metastatic  pneumonia. 

Comment. — The  interesting  factor  in  this  case  is  the  progressive 
character  of  the  affection.  The  nerve  manifestations  both  in  the  leg 
and  those  supplying  the  muscles  of  the  neck  throw  an  interesting 
sidelight  on  the  nature  of  these  affections.  Why  these  patients  pro- 
gressively weaken  and  die  is  not  apparent  in  any  of  those  I  have  ob- 
served. In  the  three  which  I  have  seen  come  to  autopsy,  no  secondary 
or  associated  lesion  was  found. 

CASE  6. — I  was  called  to  see  a  housewife  aged  sixty-three  be- 
cause of  pain  in  the  side  and  back. 

History. — Thirteen  years  ago  she  had  severe  pains  in  the  right 
upper  cjuadrant  of  the  abdomen.  An  exploratory  operation  was  done 
by  a  competent  surgeon  without  clearing  up  the  diagnosis.  Following 
this  she  began  to  lose  weight,  the  ankles  swelled,  and  she  became 
anemic.  A  tender  point  appeared  on  the  left  side  of  the  median 
line,  corresponding  to  that  on  the  right  side  present  before  the  opera- 
tion. Three  years  following  the  onset  she  developed  curvature  of 
the  spine.  She  attributed  this  to  the  constant  leaning  over  to  lessen 
the  pain.  She  improved  without  known  cause;  she  used  a  spinal 
brace  for  a  time  without  benefit.  She  was  free  from  pain  for  a  num- 
ber of  years.  Four  years  ago  the  pain  began  again  and  has  been 
present  more  or  less  since.  It  has  always  been  most  intense  at  night. 
These  pains  are  very  intense  and  follow  the  course  of  the  spinal 
nerves.     The  pain  now  is  most  intense  in  the  region  of  distribution 


300  CLINICAL    SURGERY   BY    CASE    HISTORIES 


Fig.  147. — Chronic  spondylitis. 


DISEASES    OF    THE    CHEST    AND    SPINE  301 

of  the  12th  dorsal  nerve.  The  pain  is  acute,  making  rest  impossible 
and  destrojdng  a  desire  for  food.  Pressure  relieves  the  pain  some- 
times, as  does  heat ;  when  intense,  all  of  these  measures  are  useless. 
Recently  3/8  grain  of  morphine  has  been  required  to  relieve  the 
pain.  Four  days  ago  following  a  dose  of  castor  oil  she  had  black 
stools  which  reacted  to  benzidine. 

Examination. — The  spine  shows  a  marked  curvature.  There  is  no 
tenderness  over  the  spine.  There  is  limitation  of  the  movement  of  the 
vertebrse.  The  12th  nerve  is  not  tender  to  pressure,  but  the  area 
of  greatest  pain  is  described  in  the  region  of  the  distribution  of  this 
nerve.  The  x-ray  shows  a  marked  deviation  of  the  spine  (Fig.  147). 
The  point  of  maximum  bony  change  corresponds  to  the  12th  dorsal 
vertebra  and  in  harmony  with  this  the  12th  dorsal  nerve  represents 
the  region  of  greatest  pain.  No  very  marked  exostosis  could 
be  made  out,  and  while  the  back  was  held  rigid,  there  was  an  absence 
of  definite  evidence  of  bony  union. 

Diagnosis. — Because  of  the  long  course,  malignancy  could  be  ruled 
out.  The  intercurrent  course  of  the  disease  suggests  a  rheumatic  type 
of  disease  rather  than  a  destructive  one.  The  spinal  deformity  and 
the  distribution  in  all  of  the  attacks  of  the  pain  along  the  course 
of  a  definite  spinal  nerve  suggested  pressure.  The  x-ray  did  not 
bring  the  confirmatory  evidence,  but  a  clear  x-ray  plate  could  not  be 
obtained.  A  competent  neurologist  failed  to  find  evidence  of  any  spe- 
cific type  of  cord  lesion.  The  absence  of  sensation  changes  excluded 
myelitis. 

Treatment. — Quinine  blocking  of  the  intercostal  nerves  was  at- 
tempted but  without  results. 

After-course. — The  injections  having  failed  wholly,  anodynes  were 
continued.  The  pain  increased  and  general  loss  of  strength  followed. 
She  died  after  six  weeks  of  gradually  increasing  inanition. 

Autopsy. — A  general  spondylitis  with  multiple  exostosis  with  the 
formation  of  fibrinoid  phuiues  on  the  pia  mater  was  discovered  (Fig. 
148).  The  changes  in  the  cord  membranes  apparenth'  were  of  the 
same  nature  sometimes  seen  in  the  soft  tissues  in  the  neighborhood  of 
arthritic  joints.  The  changes  in  the  spine  were  more  extensive  than 
the  distribution  of  the  pain. 

Discussion. — This  disease  was  characterized  by  the  successive  in- 
volvement of  segments  of  the  cord.  The  existence  of  pain  in  any  of 
the  regions  likely  corresponds  to  the  arthritic   process  then  active 


302 


CLINICAL  SURGERY   BY    CASE    HISTORIES 


Fig.    148. — Spinal    cord    in  chronic  spondylitis  showing  plaque  in   the   dura. 


DISEASES    OF    THE    CHEST   AND    SPINE  303 

in  some  of  the  vertebral  joints.  Any  persistent  pain  representing 
the  distribution  of  any  spinal  nerve  where  there  is  no  evidence  of 
specific  cord  disease,  should  always  excite  the  suspicion  that  there  are 
bony  changes  in  the  spine.  Even  when  these  can  not  be  demonstrated, 
search  should  be  made  for  a  primary  focus,  particularly  in  the  teeth 
and  tonsils.  The  correctness  of  this  hypothesis  is  often  demonstrated 
by  the  simultaneous  disappearance  of  the  pain  with  the  offending 
teeth  or  tonsils. 

CASE  7. — A  fanner  aged  twenty-eight  came  to  the  hospital  be- 
cause of  pain  in  his  back. 

History. — The  patient's  father  died  of  tuberculosis.  He  himself 
had  dysentery  for  three  or  four  days  two  years  ago  and  measles  one 
year  ago.  There  were  no  recognizable  sequelae.  He  was  shot  in  the 
back  with  a  load  of  No.  6  shot  nine  years  ago.  He  was  well  from 
this  in  a  month.  About  ten  months  ago  he  noticed  that  his  back  became 
very  tired  when  he  rode  farm  machinery.  This  bothered  him  again 
for  a  few  weeks  six  weeks  ago.  Ten  weeks  ago  there  was  marked  pain 
in  the  lumbar  region  when  he  straightened  up  from  a  stooping 
position.  Soon  after  this  the  pain  appeared  between  the  shoulder 
blades  and  along  the  back  of  the  neck.  There  was  some  pain  over 
the  top  of  the  left  shoulder.  Six  weeks  ago  he  noticed  a  marked 
stiffness  of  the  spine.  For  a  month  there  has  been  pain  about  the  cos- 
tal margin.  He  has  lost  fifteen  pounds  in  weight  in  the  past  ten  weeks 
and  he  has  become  markedly  weak  though  his  appetite  remains  good 
and  his  bowels  regular. 

Examination. — The  patient  looks  emaciated  and  weak.  He  holds 
his  spine  and  head  rigid,  carefully  turning  his  whole  body  when  he 
wants  to  look  about.  AVhen  he  lies  down,  he  supports  his  head  with  his 
hands.  The  lower  part  of  his  back  is  much  scarred  up  from  the  wounds 
received  from  the  shotgun,  though  the  injury  evidently  did  not  ex- 
tend below  the  deep  fascia.  The  upper  portion  of  the  spine  is  rigid 
to  movement  and  sensitive  to  deep  pressure.  His  temperature  is 
99.6°,  respiration  18,  and  pulse  84.  The  urinfe  is  strongly  acid  and 
contains  a  few  granular  casts.  There  are  13,400  leucocytes.  The 
x-ray  shows  a  deposit  of  bone  across  the  intervertebral  discs  in  the 
dorsolumbar  region  (Fig.  149),  none  in  the  upper  dorsal,  and  cervical 
region  where  he  now  has  the  most  pain.  His  tonsils  are  large,  red- 
dened and  many  white  plugs  can  be  expressed  from  them. 


304 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


Fig.   149. — Chronic  spondylitis. 


DISEASES    OF    THE    CHEST   AND    SPINE  305 

Diagnosis. — The  extent,  of  the  vertebral  column,  the  acute  onset 
and  progress  excludes  tuberculosis,  of  which  one  thinks  because  his 
father  died  of  that  disease.  The  x-ray  changes  are  distinctly  those 
of  a  hyperplastic  rather  than  of  a  destructive  process. 

Treatment. — He  was  placed  in  bed  on  his  back  without  a  pillow. 
In  a  week  his  tonsils  were  removed. 

After-course. — The  slight  temperature  he  carried  the  first  week  in 
the  hospital  gradually  disappeared  and  remained  for  the  most  part 
below  the  normal  line.  The  pain  lessened  and  the  mobility  returned. 
When  he  left  the  hospital,  he  had  regained  most  of  the  normal  mobil- 
ity in  the  cervical  region,  but  the  dorsal  region  remained  rigid,  but 
he  was  free  from  pain. 

Comment. — This  case  was  received  in  the  acute  stage,  an  unusual 
hospital  experience.  The  rather  prompt  improvement  after  the  re- 
moval of  the  tonsils  indicates  that  these  organs  w^ere  the  source  of 
the  infection. 

CASE  8. — A  farmer  aged  twenty-eight  came  to  the  hospital  be- 
cause of  pains  in  the  back  and  deformity. 

History. — His  present  trouble  started  four  years  ago  when  he  first 
noticed  a  pain  along  the  spine  in  the  thoracic  region.  These  pains 
in  a  few  weeks  began  to  pass  around  the  lower  chest  and  back 
around  to  the  abdomen  in  front.  Pains  were  not  constant.  They 
would  come  and  go  and  were  made  worse  by  exertion.  The  pains 
were  severe  all  summer  of  1914.  In  the  fall  they  decreased  and 
gave  only  a  little  trouble  until  the  summer  of  1916.  The  pains  were 
severe  all  that  summer.  In  fall  of  1916  he  quit  work  on  account 
of  a  broken  down  arch  of  his  left  foot  and  his  back  pain  disappeared 
and  gave  little  trouble  that  winter.  In  the  spring  of  1917  he  worked 
on  a  farm  and  the  pains  became  quite  severe  in  the  hips  too  at  that 
time.  He  was  very  weak  all  last  winter  and  had  some  pain.  This 
summer  the  pain  has  been  very  severe  in  the  hips.  He  noticed  the 
deformity  of  the  spine  as  early  as  four  years  ago.  He  says  it  has 
not  developed  much  in  the  interval.  Has  lost  20  pounds  in  last 
four  years.  He  has  no  cough,  but  in  the  summer  of  1916  he  had 
night  sweats  and  some  the  following  fall  and  w-inter.  Saj^s  he  had 
noticed  that  he  had  fever  in  the  afternoons  and  evenings  many  times 
but  his  temperature  has  never  been  taken   and  recorded.     He  is 


306  CLINICAL   SURGERY   BY    CASE    HISTORIES 

rather  obstinately  c'()nstii)atcd.  Tie  has  liad  a  sore  throat  for  the 
past  week. 

He  had  measles  in  childhood  and  typhoid  eleven  years  ago  when 
he  was  in  bed  two  months.  In  Jannary,  1914,  he  had  measles  a 
second  time  and  never  regained  the  strength  he  lost  at  this  time. 
Family  history  is  withont  interest.  He  has  been  repeatedly  exam- 
ined by  snrgeons,  and  a  month  ago  Avas  examined  by  an  orthopedic 
surgeon  who  diagnosed  tuberculosis  of  the  spine. 

Examination. — The  i^atient's  general  appearance  does  not  suggest 
an  invalidism  of  four  years.  The  heart  and  lungs  are  negative. 
The  tonsils  are  enlarged  and  ragged  and  there  is  a  generalized  acute 
pharyngitis.  His  teeth  are  sound.  Abdomen  negative.  Spine  more 
or  less  rigid  from  the  6th  dorsal  vertebra  down.  There  is  a  grad- 
ual ky])hosis,  the  highest  point  being  at  the  10th  dorsal.  X-ray 
examination  of  the  spinal  column  shows  a  complete  bony  ankylosis 
of  the  vertebrae  from  the  9th  to  the  12th  dorsal.  The  intervertebral 
lines  on  both  ends  of  this  area  show  rather  hazy.  The  cervical  ver- 
tebra are  rigid,  so  that  he  can  not  turn  his  head,  and  his  pillows 
must  be  aranged  to  just  fit  the  bend  of  his  neck. 

Diagnosis. — The  onset  of  his  trouble  following  an  attack  of  measles 
four  years  ago  followed  bj"  night  sweats  and  fever  favors  the  diag- 
nosis of  tuberculosis.  This  probability  is  much  heightened  by  the 
expressed  opinion  of  a  capable  orthopedist.  However,  the  character 
of  the  spinal  deformity,  together  wuth  the  rigidity  of  the  entire 
spine,  makes  this  viewpoint  questionable.  The  x-ray  shows  a  complete 
ankylosis  of  the  lower  dorsal  vertebra.  The  upper  dorsal  and  the 
cervical  show  a  shadow  along  their  borders  indicating  a  proliferative 
reaction.  The  diagnosis  is  not  apparent.  The  teeth  show  no  defect, 
and  the  tonsils,  while  ragged  and  now  acutely  hyperemic,  show  no 
crypts  and  the  history  does  not  incriminate  them. 

Treatment. — While  the  tonsils  showed  no  obvious  defect  they  were 
seized  upon  as  the  most  likely  culprits  and  enucleated. 

PatJiology. — No  abscesses  or  any  localized  infections  could  be  dis- 
covered. 

Postoperative  Course. — For  several  days  following  the  operation 
the  temperature  ranged  from  102°  to  103°.  This  temperature  was 
due  to  infection  preexisting  in  the  throat.  The  temperature  subsided, 
but  on  the  tenth  day  it  reached  102°  again. 

The  throat  has  recovered  and  the  patient  said  there  was  very  little 


DISEASES   OF    THE    CHEST   AND   SPINE  307 

pain  in  the  neck.  Examination  of  the  heart  and  lungs  show  nothing. 
The  patient  complains  of  pain  in  the  back  in  the  region  of  the  lower 
dorsal  vertebra.  The  cause  of  the  rise  of  temperature  can  not  be 
exactly  determined,  the  exacerbation  of  the  pain  in  the  spine  sug- 
gests that  the  old  lesion  has  been  stirred  up. 

Following  this  the  pain  in  the  back  rapidly  subsided  and  in  a  few 
weeks  the  rigid  areas  in  the  cervical  and  upper  dorsal  regions  began 
to  become  mobile  again.  When  he  left  the  hospital  a  month  later, 
the  head  could  be  turned  freely  and  the  spine  was  no  longer  painful. 

Comrtient. — The  x-ray  examination  in  this  case  at  once  gave  the 
positive  diagnosis.  That  the  improvement  should  be  so  rapid  follow- 
ing the  removal  of  the  tonsils  is  illuminating.  The  fact  that  no  foci 
were  discovered  in  the  tonsils  after  removal  shows  how  difficult  the 
determination  must  be  from  clinical  examination.  When  there  is  pres- 
ent a  lesion,  likely  the  result  of  a  focus  when  such  focus  can  not 
be  located  elsewhere,  the  removal  of  the  tonsils  is  justified. 

CASE  9. — A  boy  of  seven  was  brought  because  of  inability  to  con- 
trol the  bladder  and  bowels. 

History. — The  patient  seemed  normal  at  birth  save  for  a  tumor 
over  the  lower  portion  of  his  spine.  He  began  to  walk  at  fifteen 
months,  but  after  a  fever  spell  lasting  two  weeks  he  was  unable  to 
walk  for  many  weeks.  He  had  whooping  cough  at  three.  The  left 
leg  has  always  been  smaller  than  its  fellow.  It  was  early  noticed 
that  he  had  no  control  of  his  urinary  apparatus.  The  bowels  have 
always  been  constipated ;  otherwise  he  developed  normally  both 
mentally  and  physically. 

Examination. — The  lad  seems  normally  developed  for  his  age. 
He  has  adenoids  and  a  moderately  large  uniform  goiter.  The  left 
leg  is  a  centimeter  shorter  than  the  right  and  the  thigh  is  4  cm. 
smaller.  There  is  a  soft  mass  over  the  sacroiliac  juncture,  7  x  12  cm. 
(Fig.  150).  It  is  soft  and  fluctuating  and  transmits  light.  The 
x-ray  shows  a  bony  defect  at  the  base  of  the  sacrum  extending  from 
the  midline  to  the  articular  border.  Sensation  on  the  left  leg 
seems  a  little  dulled.  The  foot  is  slightly  extended  in  equinus  and 
bears  a  punched-out  ulcer  a  centimeter  across  in  the  center  of  the 
heel  (Fig.  151). 

Diagnosis. — The  entire  sac  transmits  light,  indicating  that  it  is  a 
meningocele.    Since,  however,  there  is  impaired  control  of  the  emunc- 


308 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


/* 


'J- 


^ 


Fig.    150. — Perforating    ulcer    of    the    heel    in    spina    bifida. 


Fig.    151. — Spina  bifida   showing   a   protrusion   at   the   right   border   of    the   sacrum. 


DISEASES    OF    THE    CHEST   AND    SPINE  309 

tories  and  the  ulcer  on  the  heel  indicates  destroyed  innervation,  injury 
to  or  defect  of  development  in  these  respective  nerves  must  have 
occurred.  The  important  question  is  the  determination  of  prospects  of 
improvement  following  operation.  Generally  speaking,  no  improve- 
ment can  be  promised. 

Treatment. — The  parents  were  told  that  the  tumor  could  be  removed 
but  no  change  in  innervation  could  be  expected. 

After-course. — The  condition  has  remained  unchanged. 

Comment. — When  the  emunctories  are  paralyzed  or  the  patient  can 
not  use  the  legs,  operation  is  not  warranted ;  for  no  matter  how  skill- 
fully nerves  contained  in  the  sac  are  manipulated,  function  is  not 
restored. 


CHAPTER  VIII 

DISEASES  OF  THE  BREAST 

When  a  diseased  breast  is  approaclied,  one  instinctively  asks 
whether  or  not  there  is  a  tnmor.  If  tliere  is  a  tumor,  is  it  encap- 
sulated? If  it  is  not  encapsulated  it  presumably  is  malignant  until 
it  is  proved  otherwise.  If  it  is  encapsulated  one  thinks  of  a  benign 
tumor  but  its  periphery  is  carefully  searched  for  possible  areas  of 
beginning  malignancy.  If  the  disease  is  diffuse,  one  thinks  of  an 
interstitial  mastitis,  but  one  must  assume  there  is  a  malignant  area 
in  it  until  careful  search  has  made  this  unlikely.  If  there  is  a  nodule 
in  it,  one  thinks  of  malignancy  or  a  cyst. 

NONENCAPSULATED  TUMORS 

Nonencapsulated  tumors  are  nearly  alwa^'s  malignant.  The  diag- 
nosis is  usually  so  evident  that  no  more  than  a  passing  glance  is  re- 
quired. The  diagnosis  in  this  class  of  diseases  has  to  do  with  possible 
extensions  already  present.  The  axillary  and  supraclavicular  glands 
must  be  carefully  scrutinized,  as  is  generally  recognized.  The  search 
for  accessory  symptoms,  which  might  disclose  visceral  or  bony  metas- 
tasis, is  not  as  generally  carried  out  as  the  importance  of  the  matter 
demands;  however,  no  matter  how  simple  the  diagnosis  may  seem, 
certain  points  must  be  kept  in  mind.  Fixation  of  the  nipple,  re- 
traction of  the  skin  causing  dimpling  and  the  general  hardness  of 
the  tumor  are  the  chief  factors.  When  a  tumor  is  not  definitely  pal- 
pable, then  the  dimpling  of  the  skin  when  the  breast  falls  from  side 
to  side  of  its  own  weight  and  the  higher  place  of  the  nipple  when 
the  patient  sits  upright  are  signs  of  the  greatest  value. 

CASE  1. — A  housewife  aged  fifty-two  came  to  the  hospital  because 
of  a  sense  of  uneasiness  and  pulling*  in  the  breast. 

History. — She  has  had  three  children  whom  she  nursed  without 
any  marked  disturbance  in  the  breast.  Three  months  ago  she  began 
to  have  a  sense  of  uneasiness  in  the  left  breast  which  she  unconsciously 
sought  to  relieve  by  support  from  the  hand.    This  sensation  has  been 

310 


DISEASES   OF    THE   BREAST 


311 


intermittent  but  rather  increasing  in  intensity.     She  has  had  no  pe- 
riods for  nine  montlis  and  slie  thinks  she  is  in  the  menopause. 

Examination. — There  is  no  obvious  difference  in  the  size  of  the  two 
breasts.  Both  nipples  seem  markedly  retracted  for  a  woman  who  has 
nursed  children.  The  flat  hand  does  not  detect  a  definite  tumor  in 
either  breast  but  the  left  seems  a  little  harder.  When  the  nipples 
are  pulled  upon  the  right  extends  freely  while  the  left  is  firmly 
fixed.  When  the  whole  skin  of  the  breast  is  lifted,  the  right  lifts  up 
more  freely  than  the  left.    Likewise  when  the  patient  is  turned  from 


Fig.   152. — Small  duct  carcinoma  of  the  breast. 


side  to  side  the  right  follows  the  beck  of  gravitation  to  a  greater 
extent  than  the  left  and  finally  when  the  patient  sits  upright  the  level 
of  the  left  nipple  is  higher  than  the  right. 

Diagnosis. — All  the  signs  above  enumerated  indicate  a  shortening 
of  the  connective  tissue  strands  of  the  breast,  and  though  no  definite 
tumor  is  palpable,  the  diagnosis  must  be  carcinoma  of  the  breast. 
When  the  patient  complains  of  stinging  or  burning  in  a  breast 
without  palpable  tumor  the  signs  elicitable  by  changes  of  position 
are  often  pathognomonic,  particularly  when  confirmed  by  manual 
elevation  of  the  skin.  Old  infections,  whether  they  come  to  abscess 
or  not,  may  produce  them  but  when  there  is  stinging  in  the  breast 


312  CLINICAL   SURGERY   BY    CASE    HISTORIES 

an  exploration  is  indicated  wlietlier  there  is  a  history  of  past  in- 
flammation or  not. 

Treatment. — Radical  excision,  removing  an  area  of  skin  as  large 
as  a  hand  and  the  muscles  as  well. 

Pathology. — When  a  cross  section  of  the  breast  is  studied  the  cause 
of  the  signs  is  evident.  Dense  bands  of  fibrous  tissue  extend  from 
the  nipple  (Fig.  152)  but  nowhere  form  a  definite  tumor  mass. 
The  disposition  of  these  bands  to  radiate  towards  the  skin  shows  that 
the  area  of  skin  removed  is  none  too  great.  The  section  showed  a 
small  strand  of  malignancy  beneath  and  to  the  left  of  the  nipple — an 
isolated  duct  cancer. 

After-course. — At  tlie  end  of  two  years  a  nodule  appeared  in  the 
scar  at  a  point  over  the  anterior  axillary  line.  This  was  removed  and 
she  has  remained  free  an  additional  year. 

Comment. — This  case  represents  all  the  classical  traction  signs  in  a 
striking  degree.  The  origin  of  the  tumor  antedates  much  the  ap- 
pearance of  the  symptoms  for  the  patient's  complaints  were  due  to 
contraction  of  the  fibrous  tissue  bundles.  The  recurrence  in  the  scar 
shows  an  error  in  judgment  in  estimating  the  amount  of  skin  removed. 
Skin  recurrence  impeaches  the  judgment,  recurrences  in  the  axilla 
the  technical  skill  of  the  surgeon,  only  when  recurrences  take  place 
in  the  interior  of  the  body  can  he  complacently  point  the  accusing 
finger  at  the  gods. 

CASE  2. — The  patient  aged  seventy-three  came  to  the  hospital  be- 
cause of  a  tumor  of  her  right  breast. 

History. — She  has  had  a  lump  in  her  right  breast  for  eight  months. 
There  is  no  real  pain  but  a  sticking  sensation  in  the  region  of  the 
tumor.  She  has  had  five  children,  all  of  whom  she  nursed  without 
any  accident  to  the  breast. 

Examination.— ^\\QV&  is  a  mass  2x2  xli/^  inches  in  the  upper 
quadrant  of  the  right  breast.  It  slides  on  muscles  but  the  skin  is 
attached  to  it.  The  skin  is  reddened  over  the  greater  extent  of  the 
tumor  and  is  ulcerated  over  its  center  (Fig.  153).  The  skin  is  in- 
corporated in  the  tumor.  The  tumor  is  very  dense  to  the  touch  and 
shows  some  low  bosselations  of  its  surface.  No  enlarged  axillary 
lymphatics  are  found. 

Diagnosis.- — The  presence  of  a  large  dense  tumor  with  a  reddened 
ulcerating  surface  is  characteristic  of  a  colloidal  malignant  tumor. 


DISEASES    OF    THE    BREAST  313 

Sarcomatous  tumors  when  they  destroy  the  skin  do  so  by  pressure  ne- 
crosis as  it  were  and  the  skin  is  not  attached  to  the  tumors. 

Treatment. — Wide  excision  of  the  tumor  was  made.  The  defect 
in  the  skin,  about  four  inches  in  diameter,  was  covered  with  skin 
grafts. 

After-course. — Eight  mouths  after  operation  the  patient  reported 


Fig.    153. — Colloid    carcinoma   of   the   breast   showing   the   destruction    of   the    skin   by    the   in- 
vading  tumor. 

that  several  small  lumps  had  recurred  along  the  right  side  of  the 
incision.    Further  treatment  was  not  accepted. 

Comment. — Usually  colloidal  tumors  are  of  relatively  low  malig- 
nancy and  usually  in  old  persons  there  is  less  disposition  to  recur- 
rence. Both  these  rules  failed  in  this  ease.  This  is  due  in  part  to 
an  insufficient  operation.  Whenever  recurrences  take  place  in  the 
skin,  the  operator  has  used  poor  judgment  in  outlining  his  incision. 

CASE  3. — A  matron  aged  fifty-two  came  to  the  hospital  because 
of  recurrent  pain  in  the  upper  part  of  the  abdomen. 

History. — The  patient  had  onh'  fair  health  as  a  girl,  having  had 
asthma  from  childhood  to  seventeen  years  of  age  and  rheumatism  at 
six  years  of  age,  with  a  second  attack  when  twelve  years  old  which 
kept  her  in  bed  seven  weeks.  Four  years  ago  she  had  a  severe  attack 
for  several  weeks.  She  had  typhoid  fever  when  twenty-four  years  of 
age  and  was  in  bed  five  weeks.  She  has  had  a  number  of  attacks  of  se- 
vere pain  in  the  right  side  under  the  short  ribs,  which  were  accompa- 


314 


CLINICAL   SURGERY   BY    CARE    HISTORIES 


nied  by  fever,  nausea,  and  vomiting.  The  attacks  were  followed  by  sore- 
ness all  over  the  abdomen.  The  last  attack  was  four  weeks  ago,  and 
she  still  has  some  pain  in  the  lower  chest  and  back,  but  no  abdominal 
pain.  She  has  never  been  jaundiced.  Several  months  ago  she  struck 
her  breast  against  the  edge  of  a  dishpan  and  since  has  had  a  drawing- 
in  of  the  outer  part  of  the  breast.  She  has  had  four  children  whom 
she  nursed  without  incident. 

Examination. — The  patient  is  a  plump,  well-preserved  woman,  pre- 
senting no  evidence  of  having  undergone  any  recent  suffering.  There 
is  deep  tenderness  over  the  hepatic  triangle.  Tlie  right  breast  shows 
retraction  of  the  nipple  and  a  hard  mass  the  size  of  a  hickory  nut 


Fig.   154. — Recurrent   nodule   in   breast. 

above  and  lateral  to  it.  The  outline  of  the  tumor  is  indistinct,  but 
it  glides  freely  over  the  deep  fascia  and  the  skin  is  not  attached  to 
it. 

Diagnosis. — The  history  of  recurrent  pains  in  the  right  upper  quad- 
rant radiating  to  the  back  and  attended  by  nausea  indicates  gall- 
stones, and  this  assumption  is  confirmed  by  the  deep  tenderness  in  the 
region  of  the  gall  bladder.  The  breast  tumor,  because  of  its  dense 
feel  and  retraction  of  the  nipple  indicates  carcinoma. 

Treatment. — Inasmuch  as  the  breast  carcinoma  presented  the  graver 
though  not  the  most  annoying  symptom,  a  breast  amputation  was 
done. 

Patliologij. — The  tumor  was  the  size  of  a  large  hazelnut  with  long 


DISEASES   OF    THE   BREAST  315 

brandling  fibrous  bundles  extending  from  it.  On  section  it  sbowed 
a  typical  scirrlius. 

After-course. — Healing  was  uneventful.  She  returned  after  two 
years  with  a  nodule  the  size  of  a  hazelnut  in  the  line  of  the  scar  (Fig. 
154).  This  was  widely  excised.  There  has  been  no  further  recur- 
rence in  three  years  after  the  first  operation. 

Comment. — The  fact  that  the  breast  tumor  was  a  scirrlius  makes 
it  unlikely  that  the  deyelopment  of  the  tumor  long  antedated  the  al- 
leged injury.  Most  likely  had  the  breast  not  been  sensitive  from  the 
presence  of  the  tumor,  she  would  not  have  noticed  that  she  struck 
the  dishpan.  Though  the  primary  tumor  was  small,  the  recurrence 
appeared  early  and  more  than  likely  she  will  soon  return  with  more 
evidence  of  disease.  A  plump  woman  with  large  breasts  is  lucky 
to  be  alive  three  years  after  operation. 

CASE  4. — A  matron  aged  fifty-two  came  to  the  hospital  because 
of  an  ulcer  over  the  breast  bone. 

History. — Twenty-two  years  ago  she  had  an  abscess  in  the  right 
breast  which  ruptured  just  below  the  nipple.  This  healed  and 
nothing  was  noticed  until  five  years  ago  when  she  noticed  a  lump 
just  about  the  location  of  the  abscess.  Six  months  later  the  breast 
was  amputated  and  the  axilla  cleaned  out.  A  year  and  a  half  ago 
she  noticed  a  pain  over  the  ujDper  part  of  the  breast  bone  which 
extended  through  to  the  shoulder  blade  behind  and  to  the  arm  pit. 
The  skin  seemed  fastened  to  the  breast  bone  at  this  time.  She 
worked  at  it  trj'ing  to  loosen  it  up.  Six  months  ago  the  skin  ul- 
cerated and  scabs  formed.  It  has  never  healed,  but,  on  the  con- 
trary, has  gradually  increased  in  size. 

Examination. — The  site  of  the  operation  seems  free  from  recur- 
rence. Over  the  angle  of  the  sternum  is  an  ulcerated  area  the  size  of  a 
dollar.  The  edge  is  reddened,  serrated  and  hard.  The  base  of  the 
ulceration  is  granular  and  somewhat  besmeared  with  a  greyish  exu- 
date. The  skin  surrounding  and  the  base  of  the  ulcer  is  firmly  at- 
tached to  the  bone.  There  is  no  palpatory  evidence  of  any  disease 
elsewhere.  Neither  percussion  nor  the  x-ray  show  any  trouble  in 
the  mediastinum.     Laboratory  examination  is  negative. 

Diagnosis. — The  patient  having  once  had  a  carcinoma,  any  de- 
structive disease  she  may  have  subsequently  presumably  is  of  the 
same   nature.      This    presumption   is   made   more    probable   by   the 


316 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


dense,  reddened,  serrated  outline  of  the  ulcer  itself.  The  mode  of  its 
origin  is  less  easily  determined.  It  may  be  from  lateral  extension 
from  the  breast  focus  or  from  a  metastatic  deposit  within  the  ster- 
num. The  latter  hypothesis  is  unlikely,  since  there  are  no  bony 
changes  notable  by  the  x-ray  and  the  patient  noted  a  reddening 
of  the  skin  before  enlargement  appeared.  It  seems  reasonable  to 
assume  that  the  local  condition  began  as  a  periosteal  metastasis. 
As  such  it  may  be  an  isolated  recurrence.  In  ulceration  over  the 
sternum  we  have  always  to  think  of  a  syphilitic  periostitis.    Syphilitic 


Fig.   155. — Metastatic  breast  carcinoma  in  region  of  the   scar. 

lesions  come  more  quickly,  appear  as  ovoid  elevations,  and  if  they 
do  ulcerate  they  leave  a  soft  undermined  border  quite  distinct 
from  tlie  hard  border  of  carcinoma. 

Treatment. — At  any  rate  the  affected  area  is  technically  operable 
and  the  patient  understands  a  cure  is  not  hoped  for.  The  ulcerated 
area  of  skin,  therefore,  was  Avidely  dissected  and  a  portion  of  the 
sternum  was  chiseled  off  with  it.  Skin  flaps  were  shifted  to  cover 
the  newly  denuded  area  and  the  part  so  exposed  was  covered  with 
grafts  from  the  thigh. 

Patkoloejy. — The  tissue  removed  showed  a  simple  carcinoma  start- 
ing probabh'  in  the  lymphatics  of  the  skin  (Fig.  155). 

After-course. — Healing  was  uneventful. 


DISEASES    OF    THE    BREAST  317 

Comment. — The  operations  of  local  recurrences  are  often  followed 
by  prolonged  periods  of  freedom  from  the  disease.  The  only  criterion 
we  have  to  go  on  in  determining  that  the  recurrence  is  isolated  and 
solitary  is  our  inability  to  discover  anything  elsewhere.  This  is,  of 
course,  usually  fallacious,  but  it  is  the  only  working  plan  we  have. 

CASE  5. — A  matron  ag-ed  fifty-one  was  brought  to  me  because  of 
a  tumor  of  the  breast. 

History. — Two  months  ago  she  began  to  have  a  pain  under  her 
right  arm.  She  consulted  a  doctor  who  made  a  small  incision  and  ad- 
vised poultices.  Several  weeks  later  she  noticed  a  tumor  in  the 
breast.  She  began  to  have  an  occasional  sharp,  sticking  pain  in  this 
breast  and  occasionally  a  dull  ache.  She  applied  iodine  but  received 
no  benefit.  She  consulted  her  regular  physician  who  diagnosed 
cancer.  She  has  always  had  good  health,  never  having  consulted 
a  physician  except  at  childbirths,  of  which  she  has  had  three.  In  none 
of  these  has  there  been  any  trouble  in  the  breasts,  save  that  she 
noticed  at  weaning  of  the  last  she  had  more  difficulty  in  drying  up 
the  left  than  the  right  breast.  She  passed  the  menopause  eight 
years  ago  without  any  disturbance. 

Examination. — The  patient  is  a  rugged  woman  apparently  in  the 
best  of  health.  As  she  sits  in  the  chair,  the  left  nipple  hangs  a  good 
half  inch  lower  than  the  right.  The  upper  outer  quadrant  of  the 
right  breast  is  a  reddened  area  2  inches  in  diameter.  The  borders  of 
this  shade  gradually  into  the  surrounding  skin.  This  area  is  flat- 
ter in  contour  than  the  same  area  of  the  left  breast.  As  the  pa- 
tient is  turned  from  side  to  side  this  breast  remains  rigid  and  does 
not  respond  to  the  action  of  gravitation  as  does  the  other  breast. 
Both  nipples  are  puckered.  The  axilla  of  the  right  side  seems 
fuller  than  that  of  the  left.  Careful  inspection  fails  to  find  the 
site  of  the  incision  alleged  to  have  been  made  two  months  ago. 
On  palpation  the  reddened  area  above  described  is  found  to  be 
hard,  board-like,  and  the  whole  quadrant  of  the  breast  appears 
as  a  solid  mass.  The  whole  breast  moves  freely  over  the  pectoral 
fascia,  but  the  skin  is  firmly  fixed  and  has  a  hard,  rough  corru- 
gated feel  like  an  orange.  The  nipple  is  fixed  and  does  not  respond 
to  traction,  while  the  left  does,  though  both  appear  the  same  on  in- 
spection. The  axilla  is  occupied  by  a  solid  mass  in  which  no  separate 
tumor  masses  can  be  made  out,  but  the  whole  mass  is  freely  mova- 


318  CLIXICAL   SURGERY    BY    CASE    HISTORIES 

l)le  on  the  siirrmmdiiis-  tissues.  There  are  no  supraclavicular  glands 
])alpal)le.  Both  this  mass  in  the  breast  and  the  tumor  in  the  axilla  are 
sensitive  to  firm  pressure.     All  other  examinations  are  ne^'ative. 

Diagnosis. — The  history  alone  is  confusing.  Since  after  two  months 
the  alleged  incision  has  left  no  trace  it  is  safe  to  say  it  did  not  extend 
through  the  skin.  If  anything,  she  could  have  had  nothing  more 
than  a  follicle  infection.  Most  likely  it  was  already  the  development 
of  the  axillary  mass  that  took  her  to  the  doctor.  At  this  time  neither 
she  nor  the  doctor  noticed  a  tumor  in  the  breast.  The  physical  tiud- 
ings  leave  no  doubt  as  to  malignancy.  The  elevated  and  fixed  nipple, 
the  hard  mass  in  the  breast,  the  fixation  of  the  skin  in  that  quadrant, 
and  the  mass  in  the  axilla  end  all  doubt.  The  problem  of  diagnosis 
is  that  of  operability  and  curability.  The  duration  of  the  tumor 
has  not  been  long.  Her  physician,  a  capable  and  careful  man,  exam- 
ined her  chest  repeatedly  during  an  attack  of  pneumonia  seven  months 
ago  and  found  no  tumor  in  the  breast.  While  no  special  examination 
was  made  to  determine  this  point,  he  did  make  a  careful  examination 
with  the  chest  completely  exposed.  The  fact  that  two  months  ago  she 
began  to  have  axillary  pain  and  that  now  there  is  a  mottled  mass 
here  and  a  hyperemic  skin  over  the  breast  mass  indicates  that  the 
gro^\'th  is  an  acute  one,  and  that  the  maximum  growth  has  taken 
place  in  the  last  few  months.  Such  a  rapidly  growing  tumor  in  a 
healthy,  florid  woman  with  pronounced  axillary  metastasis  indicates 
that  the  disease  is  a  very  malignant  one.  In  view  of  the  fact  that 
the  axillary  mass  is  freely  movable  and  that  there  is  no  evidence  of 
involvement  of  the  axillary  vein,  it  is  reasonably  certain  that  the 
disease  is  technically  operable.  \Ve  conclude,  therefore,  that  the 
patient  has  a  carcinoma  of  her  breast  which  is  technicall}'  operable, 
but  is  incurable. 

Treatment. — A  radical  breast  operation  was  done. 

Pathology. — The  mass  in  the  breast  is  ovoid,  about  the  size  of  a 
hen's  egg.  The  tissue  about  it  is  infiltrated  with  round  cells  and 
an  associated  hard  edema.  The  axillary  glands  are  hard  and  are 
matted  together  by  a  periglandular  exudate. 

After-course. — The  wound  healed  without  incident.  A  recurrence 
appeared  in  the  axilla  in  six  months  and  she  died  of  lung  metastasis 
nine  months  after  the  operation. 

Comment. — AVhile  the  prognosis  is  grave,  so  long  as  all  diseased 
tissue  can  be  removed,  operation  is  indicated,  for  it  at  least  gives  the 


DISEASES   OF    THE   BREAST  319 

patient  peace  of  mind  for  a  varying  period  for  which  she  exchanges 
the  pain  and  inconvenience  incident  to  tlie  operation.  Occasionally 
the  period  of  freedom  is  longer  than  one  is  led  to  expect,  and  in  rare  in- 
stances a  considerable  period  of  years  may  elapse  before  the  disease 
reappears.  If  the  patient  is  fortunate  enough  to  have  her  recurrence 
in  an  internal  organ,  she  may  escape  the  pain  incident  to  a  fatal 
local  cutaneous  and  glandular  disease. 

CASE  6. — A  woman  aged  sixty-six  entered  the  hospital  for  treat- 
ment of  a  breast  tumor  considered  inoperable  because  of  heart  dis- 
ease. 

History. — General  health  has  always  been  good  except  for  heart 
trouble.  She  knows  no  cause  for  this.  She  has  taken  heart  medicine 
for  paliDitation  and  shortness  of  breath  for  some  time. 

Three  months  ago  she  first  noticed  a  lump  in  her  breast.  She  has 
some  dull  pain  in  it.  Her  phj'sician  said  it  could  not  be  removed  be- 
cause she  could  not  take  an  anesthetic  on  account  of  her  heart. 

Examination. — The  patient  is  a  thin  woman  who  shows  some  dysp- 
nea on  exertion.  The  lungs  are  negative.  The  heart  is  in  the  mid- 
sternal  line  at  the  fifth  interspace.  There  is  a  systolic  murmur  at  the 
base.  There  is  a  moderate  arteriosclerosis.  No  edema.  The  left  breast 
presents  a  flat,  hard  tumor  in  its  outer  quadrant.  It  is  irregular  in 
outline  and  follows  a  tug  on  the  nipple  and  there  is  pitting  in  the 
skin  along  the  outer  border  of  the  breast  when  the  nipple  is  pulled 
sharply  toward  the  median  line.    There  are  no  palpable  glands. 

Diagnosis. — The  irregular  and  dense  character  of  the  tumor  allows 
no  doubt  as  to  the  diagnosis  of  carcinoma.  The  position  of  the  mur- 
mur indicates  a  mitral  stenosis.  The  fact  that  the  left  heart  is  en- 
larged suggests  that  there  must  be  an  associated  regurgitation.  The 
disposition  to  dyspnea  indicates  a  moderate  decompensation.  This 
with  the  character  of  the  valve  lesion  would  make  the  giving  of  a 
general  anesthetic  hazardous. 

Treatment. — In  consideration  of  the  heart  lesion,  the  amputation 
was  done  with  novocain-epinephrin  solution.  The  breast  was  first  loos- 
ened and  with  the  breast  as  a  tractor  the  axillary  contents  were 
everted  by  traction.  In  this  way  the  axillary  vein  was  brought  into 
view  together  with  all  the  associated  structures    (Fig.   156- J..) 

Pathology. — On  section  (Fig.  156- JL)  a  dense,  granular  mass  is  seen 
to  occupy  the  lateral  portion  of  the  gland.     There  are  many  fibrous 


320 


CLINICAL   SURGERV    BY    CASE    HISTORIES 


Fig.    156-^. — Carcinoma   of  the  breast  with  axillary   contents. 


DISEASES    OF    THE    BREAST 


321 


bands  radiating  toward  the  nipple,  and  a  few  projecting  toward  the 
skin  over  the  lateral  border  of  the  breast.  These  bands  explain  the 
disposition  of  the  tumor  and  skin  to  follow  the  traction  on  the  nipple 
noted  in  the  examination;  though  there  was  no  actual  retraction  of 
the  nipple.  Xo  lymph  glands  were  found.  The  section  shows  a 
preponderance  of  fibrous  tissue,  therefore  a  scirrhus. 

After-course. — Healing  was  uneventful.     During  the  week's  stay 
in  bed  together  with  strophanthus  the  heart  improved. 


Skin    recurrence    in    carcinoma    of    the    l)rea?t. 


Comment. — The  proguo.si.s  in  this  case  is  good,  lu  spare  woman 
beyond  the  menopause  hard  tumors  give  a  very  good  prognosis.  The 
patient  noticed  the  tumor  only  three  months  before  operation.  A 
scirrhus  does  not  develop  so  rapidly  in  an  old  woman  and  it  may  be 
assumed  that  the  actual  period  of  development  exceeded  this  mani- 
fold. 

Note. — Despite  the  above  prediction,  the  patient  returned  in  a  year 
and  a  half  with  a  recurrence  in  the  line  of  the  scar  (Fig.  156-5).  An 
insufficient  operation  must  be  ascribed  as  the  cause.  The  recurrence 
healed  under  the  x-ray. 


322  CLINICAL    SURGERY    BY    CASE    HISTORIES 

CASE  7. — A  housewife  aged  thirty-six  came  to  the  hospital  be- 
cause of  a  lump  in  her  breast. 

History. — The  patient  has  had  nine  children,  the  youngest  is  two 
months  old.  After  the  birth  of  the  second  last  child  two  years  ago, 
lier  breast  became  inflamed  and  never  fully  recovered.  After  she 
weaned  this  child  the  breast  continued  gradually  to  enlarge.  It  was 
somewhat  painful  but  never  caused  much  inconvenience.  After  the 
birth  of  the  last  child  two  months  ago  it  became  painful  and  began 
to  enlarge  more  rapidly. 

Examination. — A  tumor  occupies  the  upper  quadrant  of  the  left 
breast.  It  is  the  size  of  a  lemon,  is  hard  and  shows  an  irregular  sur- 
face. These  irregularities  of  the  surface  are  hard  and  seem  to  be 
the  agencies  by  which  the  tumor  is  more  or  less  fixed  to  the  surround- 
ing skin.  The  skin  is  attached  to  it  but  is  not  reddened,  and  the 
nipple,  while  not  retracted,  is  fixed.  The  axillary  space  is  sensitive, 
but  no  definite  glands  can  be  palpated  though  because  of  her  adi- 
posity examination  is  unsatisfactory.  Blood  and  urine  are  without 
interest. 

Diagnosis. — The  density,  the  gradual  onset,  the  limited  pain,  the 
fixity  of  the  skin  makes  the  diagnosis  easy.    It  must  be  a  carcinoma. 

Treatment. — A  radical  breast  amputation  was  done.  There  were 
a  number  of  palpable  glands  found  when  the  axilla  was  exposed. 
These  were  suspiciously  soft,  but  the  mammary  tumor  when  exposed 
gave  palpatory  evidence  of  malignancy  and  was  not  cut  into. 

Pathology. — Much  to  my  amazement,  when  the  tumor  Avas  cut  into  it 
proved  to  be  not  a  carcinoma  but  a  chronic  abscess.  The  abscess  itself 
was  as  large  as  an  unhulled  walnut.  This  was  surrounded  by  a  wall 
nearly  an  inch  thick  (Fig.  157).  This  was  made  up  of  chronically 
infiltrated  breast  tissue  which  felt  hard.  The  cellular  infiltration 
is  made  up  mostly  of  plasma  cells  (Fig.  157).  This  accounts  for 
the  dense  feel  of  the  tissue.  The  sensation  to  the  finger  was  very 
much  like  that  often  seen  about  chronic  indurated  ulcers  of  the 
stomach.  The  contents  of  the  abscess  was  not  examined,  because 
after  I  recovered  my  composure,  it  had  all  been  lost. 

After-course. — Kecovery  was  uneventful  and  she  has  remained 
well. 

Comment. — The  beginning  of  this  tumor  two  years  ago  during  lac- 
tation should  have  been  sutficient  clew  to  prevent  error.  Had  it 
been  a  carcinoma  at  that  time,  in  a  lactating  breast,  she  would  not 


DISEASES    OF    THE    BREAST 


323 


have  been  alive  to  bear  another  child  two  rears  later.  Had  I  cnt  into 
the  breast  during  the  course  of  the  operation,  the  irritating  fluid 
might  have  stimulated  bacteria  to  sufficiently  vigorous  growth  to 
have  caused  trouble. 

On  the  whole,  removal  of  the  breast  may  have  been  the  best  thing 
to  do,  for  the  tissue  so  long  indurated  would  have  left  a  discharging 
sinus   for   an   indefinite   period.      The   axilla   should   have   been  left 


B. 


Fig.    157. — Chronic   abscess   of   the   breast   simulating   carcinoma    of  the   breast.     A.   Gross   ap- 
pearance   of   the   abscess.      B.   Slide   of    its   wall. 


324 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


unmolested,  however.  In  rare  instances  one  finds  just  sucli  condi- 
tions whicli  have  a  border  of  uialignanc}-.  One  can  not  know  in  these 
cases  whether  the  malignancy  developed  about  an  abscess  or  whether 
an  abscess  formed  in  a  malignant  area.  My  opinion,  from  a  study  of 
the  cell  content  and  topography,  is  that  the  first  of  these  possibili- 
ties obtains.  If  such  is  the  case,  the  amputation  of  the  breast  for 
chronic  abscess  is  no  calamity,  particularly  in  persons  whose  esthetic 
sense  is  submerged  in  the  cares  of  a  large  retinue  of  offspring,  as 
in  this  case. 

CASE  8. — A  widow  aged  ninety-two  came  to  me  because  of  a 
tumor  of  the  nipple. 

History. — For  many  years  she  has  had  a  nub  on  tlie  end  of  her  nip- 
ple. Recently  it  has  grown  rapidly  and  the  rubbing  of  the  clothing 
causes  it  to  bleed. 


Fig.    ISS-.l. — Carcinoma   of   the   nipple. 

Examination. — On  the  end  of  an  attenuated  nipple  two  inches  long 
(Fig.  158- A)  is  a  tumor  li/o  by  21/2  inches.  It  is  dense  and  is  covered 
with  incrustations  which  when  removed  leave  bleeding  areas. 


DISEASES    OF    THE    BREAST 


325 


Diagnosis. — Its  density  and  tendency  to  bleed  indicate  malignancy. 
Treatment. — The  base  of  the  nipple  was  circumscribed  by  an  ellip- 
tical incision. 

Pathology. — The  cross-section  shows  a  mottling  of  white  and  pink. 


Fig.    1S8-B. — Cross   section   of   a   carcinoma   of   the   nipple. 

The  white  areas  are  finely  granular  (Fig.  158-5).  The  slide  shows  a 
cellular  carcinoma.     The  nipple  is  free  from  invasion. 

After-course. — Healing  was  prompt  and  recovery  should  be  per- 
manent. 

Comment. — It  is  curious  that  the  apex  of  the  nipple  should  de- 
velop such  a  huge  tumor. 

CASE  9. — I  was  asked  to  see  a  matron  aged  fifty-two  who  was 
complaining'  of  pains  in  the  arms  and  a  tumor  of  the  breast. 

History. — The  patient  has  always  been  an  invalid.  Now  for  a 
week  she  has  had  pain  and  swelling  in  the  right  arm.  She  has  been 
married  twenty-one  years,  has  had  no  living  child  but  had  a  mis- 
carriage eighteen  years  ago.  She  has  had  uterine  trouble  for  eleven 
years.  Menses  irregular  and  too  profuse,  now  has  almost  constant 
bleeding.    She  had  typhoid  fever  twenty-five  years  ago. 

Examination. — The  patient  looks  thin,  exhausted,  and  anemic.  The 
right  arm  is  swollen  and  boggy  to  the  feel.  The  right  breast  is 
fixed  to  the  underlying  fascia  and  the  nipple  is  fixed  and  retracted. 
Cyst  in  the  left  breast  from  which  a  sinus  is  discharging  a  serous 
fluid.  The  right  sternomastoid  muscle  is  fixed  and  hard,  producing 
a  torticollis.  The  muscle  stands  out  as  a  firm  strand.  No  supra- 
clavicular glands  can  be  made  out  but  the  fossa  seems  to  have   a 


326 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


firm  bottom  making  it  impossible  to  differentiate  any  structures. 
Blood  Hg.  90x,  r.b.e.  4320000,  w.b.c.  7000.  Polynuclears  41  (Im.,  6, 
ambo.  8,  neutro.  15,  base  11,  deg.  1)  eos.  3,  mast.  3,  monos.  53.  Hya- 
line 36,  small  13  (5  possil)le  plasma)  large  4.  Platelets  decreased. 
Bp.  120. 

Diagnosis. — Tbe  cyst  of  tbe  breast  with  the  discharging  sinus  is 
best  regarded  as  a  papillary  cyst  which  has  become  malignant.  The 
swelling  of  the  arm  and  the   affection  of  the  muscles  of  the  neck 


Fig.    159. — Carcinoir.a   en   cuirasse. 


suggests  a  sclerosing  metastasis  despite  the  fact  that  no  definite 
tumor  masses  can  be  made  out.  The  apparent  rather  sudden  onset 
might  suggest  an  inflammatory  process  or  a  sclerosing  type  of  Hodg- 
kin's  disease.  There  was  no  evidence  of  local  reaction  and  Hodg- 
kin's  rarely  infiltrates  the  surrounding  tissues  sufficiently  to  ob- 
struct the  venous  or  lymphatic  return.  The  blood  picture  is  that 
of  an  indefinite  aplasia  but  substantiates  none  of  the  hypotheses 
enumerated. 

Treatment. — The    condition    obviously    was    not    surgical.      X-ray 
and  general  treatment  was  followed. 


DISEASES    OF    THE   BREAST  327 

After-course. — Six  months  later  the  right  arm  was  still  swollen. 
The  right  breast  was  bound,  down  tight  to  the  chest  wall  due  ap- 
parently to  a  sclerotic  process  originating  in  the  lymph  dncts  and 
glands  which  were  reddened,  swollen  and  slightly  tender.  Through- 
out the  skin  of  the  chest  are  many  nodules  the  size  of  a  grain  of  wheat 
to  that  of  a  pea.  These  seem  to  be  seated  in  the  skin  and  are  more  evi- 
dent to  the  touch  than  to  sight.  Between  each  of  these  and  the  under- 
Ijang  tissues  there  seems  to  be  an  attachment.  The  left  side  of  the 
chest  likewise  is  affected  and  the  breast  of  that  side  is  mottled, 
fixed  and  the  nipple  is  retracted.  These  nodules  and  indurated  skin 
form  a  belt  about  10  inches  wide  which  nearly  encircles  the  entire 
chest  (Fig.  159).  This  picture  is  typical  of  the  so-called  carcinoma 
en  cuirasse.  It  is  only  in  the  last  four  weeks  that  the  nodes  have 
appeared  across  the  median  line  and  about  the  left  breast.  The 
patient  has  had  no  menses  the  past  year,  and  has  gained  two  pounds 
in  weight.  The  blood  picture  remains  almost  identically  as  above 
recorded.  The  patient  died  about  six  months  later  from  the  har- 
assing pain  and  inanition. 

Comment. — This  type  of  carcinoma  usually  appears  as  a  diffuse 
carcinoma  of  a  breast  gradually  involving  the  skin  secondarily,  finally 
reaching  the  neighboring  hnnph  glands  late  if  at  all.  The  process  is 
that  of  a  carcinomatous  lymphangitis  with  conglomerate  proliferation 
here  and  there  forming  palpable  nodules.  In  this  instance  there 
evidently  was  a  metastasis  to  the  axillary  and  supraclavicular  glands 
early.  The  condition  is  always  hopeless.  The  peculiar  blood  pic- 
ture suggests  that  there  may  have  been  an  early  marrow  metastasis. 
In  view  of  the  patient's  confirmed  invalidism  it  is  equally  likely 
that  there  was  an  undetermined  constitutional  state  responsible  for  it. 

CASE  10. — A  matron  aged  fifty-f our  sought  consultation  because 
of  a  tumor  of  the  breast. 

History. — One  year  ago  the  patient  noticed  a  small  knot  in  the 
left  breast.  She  has  had  five  children  all  of  whom  she  nursed  with- 
out incident.  Several  months  ago  she  had  a  pain  in  the  back.  A 
sojourn  at  the  Springs  did  no  good,  in  fact,  the  pain  became  aggra- 
vated instead  of  better. 

Examination. — A  nodule  the  size  of  a  walnut  occupies  the  upper 
outer  quadrant  of  the  left  breast.  The  tumor  is  somewhat  attached 
to  the  skin  but  it  glides  freely  over  the  pectoral  fascia.     The  nipple 


328  CLINICAL   SURGERY    BY    CASE    HISTORIES 

is  not  retracted  but  lies  on  a  plane  half  an  inch  higher  than  the  un- 
affected side  when  the  patient  sits  upright,  with  both  breasts  de- 
pendent. The  axillary  glands  are  free.  There  is  tenderness  over 
the  vertebriP  at  the  seventh  cervical  and  the  patient  moves  the  head 
backward  with  hesitancy.  The  x-ray  shows  rarefaction  of  the  first 
dorsal  vertebra. 

Bkignosis. — The  elevation  of  the  nipple  in  the  dependent  breast 
together  with  the  tumor  is  sufficient  evidence  to  warrant  the  diag- 
nosis of  malignancy,  though  there  is  no  retraction  or  fixation  of  the 
nipple.  The  x-ray  shows  a  lesion  in  the  body  of  the  first  dorsal  ver- 
tebra and  taken  in  connection  with  the  findings  on  the  breast,  char- 
acterizes it  as  a  metastatic  nodule.  It  likewise  makes  the  breast 
tumor  unsurgical. 

Treatment. — The  breast  tumor  is  operable,  but  this  procedure  is 
useless  in  view  of  the  metastasis  in  the  spine.  Despite  the  urgent 
wishes  of  the  patient,  operation  was  refused. 

After-course. — A  colleague  amputated  the  breast  despite  the  spinal 
trouble,  apparently  ignoring  its  significance.  The  spinal  trouble 
grew  rapidly  worse  and  the  patient  never  left  her  bed  after  the 
operation,  dying  seme  nine  months  later. 

Comment. — In  carcinomas  of  the  breast,  more  than  in  any  other 
tumor  the  general  liodily  condition  must  be  scrutinized  lest  some 
metastasis  be  overlooked.  This  patient  failed  to  make  anj'  reference 
to  the  trouble  in  her  neck  when  first  interrogated,  and  when  the 
difficulty  in  turning  her  head  was  noted  she  insisted  that  she  fre- 
quently had  various  pains  in  her  back  of  no  significance.  It  was 
only  by  careful  quizzing  that  a  history  of  the  pain  high  in  the  back 
could  be  separated  from  miscellaneous  lumbar  and  sacral  pains  of 
the  childbearing  period.  She  seemed  intuitively  to  recognize  the 
pains  as  something  ominous  Avhich  she  sought  to  minimize  by  re- 
fusing to  recognize  them.  I  have  noticed  this  tendency  in  a  number 
of  instances.  The  only  safeguard  is  to  think  of  the  possibility  of  me- 
tastasis in  bones  as  well  as  the  axilla  in  every  case  of  breast  car- 
cinoma. 

CASE  11. — A  woman  aged  fifty-six  came  to  the  hospital  because 
of  a  tumor  of  the  chest. 

History. — For  a  number  of  years  she  has  noticed  a  tumor  develop- 
ing along  the  upper  border  of  her  right  breast.     It  has  alwavs  been 


DISEASES   OF    THE   BREAST 


329 


hard  and  but  little  painful,  though  at  times  she  has  some  discom- 
fort. Her  general  health  has  always  been  good  and  she  had  no  trou- 
ble with  her  breast  during  any  of  her  five  pregnancies. 

Examination. — Beginning  just  below  the  clavicle  is  a  large  tumor 


Figi.    160-A. — Desmoid   of  the  pectoral   region. 


fh 


I- 


■ "  X  /    '' 


f,h 


Fig.    160-B. — Desmoid  of  the  pectoral   region.     I.  Increase   of  fibrous   tissue  in  the   subdermal 
region.     2.   Fibrous  tissue  replacing  the  muscle  tissue  of  the  pectoralis  major. 


660  CLINICAL   SURGERY   BY    CASE    HISTORIES 

Avhich  extends  dowmvard  for  four  inches  where  it  seems  to  suffuse 
with  the  fairh*  prominent  mammje.  The  skin  near  the  tumor  is  not 
discolored,  neither  are  the  veins  dilated.  On  touch  the  skin  is  felt 
to  be  movable  over  the  tumor,  but  the  tumor  is  quite  firmly  fixed 
to  the  underlying  structures.  The  tumor  is  firm  and  quite  pain- 
less. It  is  not  distinctly  encapsulated.  The  breast  seems  to  be 
free  from  the  tumor  and  is  unchanged.  Other  examinations  are 
negative. 

Diagnosis. — A  large,  very  dense  tumor  in  this  situation  is  unusual. 
A  mixed  tumor  or  a  fibroadenoma  going  out  from  the  upper  border 
of  the  breast  should  be  movable,  bosselated  and  completely  encap- 
sulated. Its  density  suggests  a  fibrosarcoma  going  out  from  the 
pectoral  fascia.  This  diagnosis  is  not  wholly  satisfactory  because 
of  its  slow  growtli  and  for  the  fact  that  there  are  no  enlarged  veins 
in  the  skin  wliich  should  be  the  case  were  the  tumor  malignant. 

Treatment. — Tlie  tumor  with  the  attached  surrounding  fibrous 
tissue  was  excised.  It  was  found  to  be  entirely  free  from  the  breast 
but  incorporated  the  pectoral  fascia,  and  some  of  the  muscle  was 
cut  away  with  the  tumor. 

Patliologij. — TVhen  the  tumor  is  cut.  it  is  found  to  be  very  dense 
and  it  cuts  Avith  difficulty.  The  surface  is  mottled  with  whitish  and 
pinker  areas.  The  Avhite  areas  show  a  distinct  fibrillation  (Fig. 
160-J.).  The  section  shows  in  the  denser  portion  a  distinctly  fibrous 
tissue,  while  in  the  pinker  areas  a  fibrous  tissue  with  small,  more 
spheroidal  cells  is  intermingled  with  compressed  striated  muscle  fibers 
giving  the  picture  of  a  sclerosing  myositis  (Fig.  160-5).  It  may  be 
classified  as  a  desmoid. 

After-course. — The  relief  has  been  permanent  now  for  five  years. 

Comment. — This  type  of  tumor  is  usually  found  in  the  recti  mus- 
cles of  women  who  have  borne  children,  and  are  supposed  to  be 
the  result  of  partial  rupture  of  the  muscle  in  childbirth.  There 
was  no  history  in  this  case  of  any  undue  strain  to  the  pectoral  mus- 
cles. 

CASE  12. — A  housewife  of  sixty-one  came  for  consultation  be- 
cause of  an  ulcer  in  the  left  breast  in  an  operative  scar. 

History. — The  patient  had  a  small  lump  in  the  left  breast  with 
retraction  of  the  nipple ;  it  grew  in  one  year  to  the  size  of  an  unhulled 
walnut.    It  was  removed  a  year  ago.    The  wound  healed  up  perfectly 


DISEASES    OF    THE    BREAST 


331 


well  and  the  scar  has  been  firm  until  six  weeks  ago,  when  she  first 
noticed  bleeding  in  the  inner  angle  of  the  scar.  Since  then  there 
has  developed  an  nicer  which  is  increasing  in  size  rather  rapidly. 
Xo  pain  save  tenderness  at  times.  General  health  is  good.  There 
is  some  aching  under  the  tip  of  the  right  shoulder  blade  which  is 
worse  on  doing  hard  work. 

Examination. — The  patient  is  well  developed  and  well  nourished, 
does  not  look  acutelv  ill.    Has  several  warts  on  the  face  and  telangiec- 


Fig.    161. — Cancerous   ulcer   following  operation   for   carcinoma  of   the   breast. 

tatic  area  over  the  chest.  There  are  no  palpable  glands  in  the  neck 
except  two  hard,  small  nodules  above  the  left  clavicle.  The  right 
breast  has  been  removed.  The  scar  of  the  operation  extends  from 
anterior  axillary  line  to  region  of  nipple  and  from  this  point  down 
and  out  about  12  cm.  long.  At  the  angle  of  the  scar  is  an  ulcer 
about  3  cm.  across,  with  sharp  edges,  and  0.5  to  1  cm.  deep.  Surface 
below  looks  red,  bleeds  readily  on  manipulation,  edges  clear  cut,  and 
hard  (Fig.  161).  Area  over  ribs  lateral  to  scar  is  tender.  Xo  glands 
felt  in  axilla.     Lungs  normal,  heart  slow,  distant,  regular,  sounds  at 


332  CLINICAL    SURGERY    BY    CASE    HISTORIES 

base  somewhat  muffled,  no  murmurs.  Right  breast  firm,  red,  and 
board-like. 

Diagnosis. — Recurrent  carcinoma  of  the  left  breast  with  metastasis 
above  left  clavicle  is  evident.  She  is  told  cure  is  impossible,  but  she 
desires  to  be  rid  of  the  pain  and  annoyance  of  the  ulcer. 

Treatment. — The  ulcer  on  the  left  chest  was  widely  dissected  out, 
and  nodules  in  left  supraclavicular  space  removed.  The  wound  covered 
with  skin  by  shifting  a  flap.  A  drainage  opening  was  made  in  left 
side  of  the  flap  and  gauze  drain  inserted. 

After-course. — The  drain  was  removed  from  the  w^ound  the  fourth 
day  and  all  the  sutures  except  three  where  the  skin  flaps  were  brought 
together,  were  removed  on  the  seventh  day.  The  rest  of  the  sutures 
were  removed  on  the  eleventh  day,  the  wound  was  healed  except  for 
two  places,  one  where  the  skin  was  incised  and  sutured  in  opposite 
directions  to  remove  tension  and  one  where  three  skin  flaps  were 
brought  together.  Wound  in  the  neck  completely  healed.  The  patient 
was  dismissed  on  the  twelfth  day  after  operation.  The  patient  re- 
turned in  two  months.  The  skin  over  the  whole  front  of  chest  to 
above  the  chest  was  hardened,  slightly  pebbly  feel  and  red.  This  was 
obviously  a  carcinoma  en  cuirasse. 

Comment. — Though  the  patient  was  told  cure  was  not  to  be  ex- 
pected she  was  much  displeased  at  the  result.  Evidently  what  ap- 
peared as  telangiectatic  areas  were  mestastases  already  beginning. 
The  ulcer  was  regarded  as  a  breaking  down  of  the  scar,  but  it  was  in 
reality  a  malignant  degeneration. 

CASE  13. — A  housewife  aged  twenty-eight  came  to  the  hospital 
because  of  a  mass  in  the  right  breast  with  an  ulcerated  area  over 
it,  and  pain  in  the  right  side. 

History. — The  patient  noticed  a  lump  in  the  right  breast  five  years 
ago.  It  was  about  the  size  of  a  bean,  not  painful,  and  apparently 
rolled  around  under  the  skin.  It  was  just  to  the  outer  side  of  the 
nipple.  It  did  not  grow  until  a  year  ago,  after  an  attack  of  influ- 
enza. She  weaned  her  baby  at  the  time,  and  the  breast  became  en- 
gorged and  painful.  When  this  disappeared  she  noticed  the  tumor 
was  growing,  and  since  then  there  has  been  sharp  sticking  pain  in  it 
at  times.  Eight  months  ago  a  doctor  treated  the  tumor  with  caustic 
plasters.  An  area  the  size  of  a  saucer  was  denuded  and  the  breast 
supposedly  removed.    Two  weeks  ago  her  physician  discovered  a  lump 


DISEASES    OF    THE    BREAST  333 

in  the  right  axilla  and  told  her  to  consult  a  surgeon.  Since  the  birth 
of  the  last  baby  two  years  ago  she  has  had  a  pain  in  the  right  side. 
This  pain  is  just  inside  the  anterior  superior  spine  of  the  ileum. 
It  is  localized  in  a  small  area  and  does  not  radiate.  She  has  had 
attacks  of  epigastric  cramps  with  vomiting.    They  usually  come  on  in 


Fig.   162-A. — Scar  after  treatment  of  carcinoma  of  the  breast  by  a  plaster. 

the  morning  before  breakfast.  They  come  as  often  as  twice  a  week. 
She  has  never  had  generalized  abdominal  pain  with  vomiting  and 
fever.  She  is  troubled  considerably  with  i^ains  low  in  the  back.  They 
come  any  time,  but  are  worse  at  the  periods.  She  has  a  j^rofuse 
leucorrhea. 

Examination. — The  patient  looks  somewhat   anemic,  but  does  not 
look  acutely  ill.     The  left  breast  is  small,  no  masses  or  areas  of  ten- 


334  CLINICAL   SURGERY   BY    CASE    HISTORIES 

derness.  The  right  breast  presents  a  scar  which  is  ulcerated  over 
the  center  of  the  scar  (Fig.  162-.1).  There  is  a  mass  under  the  scarred 
area  which  is  hard,  movable,  and  nodular.  There  are  several  small 
nodules  in  the  right  axilla  which  are  hard  and  somewhat  tender. 
Lung  expansion  is  good  on  both  sides,  normal  resonance,  no  rales, 
no  increased  vocal  or  tactile  fremitus.  There  are  no  palpable  masses 
in  the  abdomen.  The  perineum  is  lacerated  to  the  second  degree.  The 
cervix  is  deeply  bilaterally  lacerated  and  discharges  a  thick  pus. 
Small  hemorrhoids,  not  ulcerated.  Retlexes  all  rather  exaggerated. 
Urine  1,018,  albumen  present. 

Diagnosis. — The   history   of    a   small   movable   tumor   suggests    an 
adenoma.     This  grew  and  a  plaster  was  applied.     This  is  a  familiar 


Fig.    162-B. — Cross   section    of   the   preceding   sliowirig   tlie    large   cancer    nodule    in    the    center. 

historj^  of  the  treatment  of  benign  growth  by  cancer  quacks.  The 
mass  here  presented  evidently  is  something  out  of  the  ordinary.  It  is 
dense  but  moves  over  the  underlying  fascia.  The  borders  are  hard 
and  nodular  and  not  encapsulated.  It  suggests  a  mastitis  or  a  malig- 
nancy. The  overlying  scar  is  so  dense  that  palpation  is  unsatisfac- 
tory. It  does  not  seem  as  though  a  malignancy  could  have  recurred 
to  such  an  extent  in  so  short  a  time.  If  it  is  malignant,  it  must  rep- 
resent the  original  breast,  the  skin  only  having  been  destroyed  by  the 
plaster.  The  axillary  glands  are  as  large  as  hazelnuts  and  are  not 
hard  as  one  would  expect  cancerous  glands  to  be.  It  seems  removal 
alone  can  decide  the  problem.  The  history  of  vomiting  and  pain  in 
the  back  causes  one  to  pause  lest  one  overlook  metastases  already 


DISEASES    OF    THE    BREAST  335 

present.  The  backache  is  predominantly  sacral  and  is  worse  at  the 
menses.  The  epigastric  pain  was  present  to  some  degree  for  a  time 
six  years  ago.  It  seems,  therefore,  that  the  hazzard  of  overlooking 
a  metastasis  is  minimal. 

Treatment. — The  mass  representing  the  right  breast  was  removed 
preceded  by  a  dissection  of  the  right  axilla.  The  wound  was  com- 
pletely covered  with  skin  by  shifting  flap. 

Pathology. — The  mass  removed  was  as  large  as  the  palm  of  one's 
hand  and  an  inch  thick.  The  cut  surface  is  mottled  and  punctiform 
(Fig.  162-5).     The  slide  confirms  the  suspicion  of  malignancy. 

After-course. — The  patient  suffered  some  shock.  Pulse  130  and  very 
weak  after  operation.  Temperature  went  to  97,  with  a  pulse  of  60 
in  the  evening  following  the  operation.  The  after-course  was  un- 
eventful. The  wound  healed  except  a  small  area  about  2  cm.  across 
where  the  skin  was  under  too  great  tension  when  the  patient  was  dis- 
missed ten  days  after  operation.  The  patient  reported  three  weeks  af- 
ter going  home  that  she  was  feeling  well  except  for  pain  in  the  left 
leg  in  the  calf  muscles.  Three  months  later  again  she  reported.  Her 
right  arm  became  stiff  following  washing  one  week  before.  No  trouble 
in  the  left  leg  at  that  time.  Pain  in  the  abdomen  was  as  bad  as 
before,  worse  at  the  periods,  not  continuous.  The  right  arm  could 
not  be  straightened  completely,  no  pain,  no  swelling,  no  axillary  nodes 
in  the  right,  but  a  small  one  in  the  left.  Left  breast  negative.  The 
scar  four  months  after  operation  showed  a  small  recurrence.  This 
was  removed  by  the  cautery.  Three  months  later  there  is  no  recur- 
rence. 

Comment. — It  is  possible  that  a  benign  tumor  was  stimulated  to  ma- 
lignancy by  the  irritation  of  the  plaster.  Possibly  the  whole  breast 
was  so  stimulated.  The  area  involved  at  operation  makes  such  an 
assumption  tenable.  If  one  could  have  been  sure  of  the  diagnosis 
it  would  have  been  better  not  to  have  operated.  Surgery  gets  the 
blame  for  the  failure  to  cure.     It  will  most  certainly  recur. 

CASE  14. — ^A  matron  aged  forty-five  came  because  of  pain  in  her 
left  breast. 

History. — Six  months  ago,  without  known  cause,  her  left  breast 
began  to  be  painful.  It  was  somewhat  swollen  and  was  sensitive  to 
pressure,  but  there  was  little  or  no  spontaneous  pain.  She  had  trouble 
with  this  breast  when  she  nursed  the  last  child  eight  years  ago,  but  she 


336 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


continued  to  nurse  despite  the  pain.     Her  general  health  has  always 
been  good. 

Examination. — The  breast  is  generally  enlarged  and  the  nipple  is 
prominent  and  looks  edematous.  The  skin  covering  the  whole  breast 
is  mottled  red.     The  whole  surface  is  hard  V)eneath  the  skin  and  the 


Fig.    HjZ-A. — Skin    over   a    rapidly   developing   carcinoma.      The    dimpling   of    the    skin    is    well 

marked. 


skin  has  a  boggy  feel.  The  whole  skin  area  is  pitted,  a  typical 
peau  d'orange  appearance  (Fig.  163-^).  The  whole  breast  is  sensi- 
tive to  pressure.  There  are  several  glands  in  the  axilla  the  size  of 
beans. 

Diagnosis. — The  firm  feel   and  the  dimpled  skin   is  diagnostic  of 
carcinoma.     The  redness  indicates  a  very  malignant  type  and  the 


DISEASES    OF    THE    BREAST 


337 

The 


glands  in  the  axilla  attest  to  metastasis  already  in  progress 
patient  is  very  anxious  that  an  attempt  be  made  to  relieve  her. 

Treatment. — An  area  of  skin  5x8  inches  was  removed.   This  seemed 
to  take  in,  with  a  wide  free  margin,  the  affected  area.    The  axilla  was 


Fig.     163-B. — Recurrent    carcinoma    six    weeks    after    operation.      The    area    about    tlie    scar    is 

diffusely   hardened. 


dissected  out  with  care,  the  pectoral  muscles  together  with  a  very 
wide  area  of  fascia  were  removed.  The  wound  was  closed  with  wide 
sliding  flaps.  The  ribs  were  so  completely  denuded  that  grafting 
seemed  inadvisable. 

Pathologij. — The  breast  was  diffusely  affected.     The  slide  showed 


338 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


an   extensive   malignancy,   the   cells   being   arranged   tandem   rather 
than  in  nests. 

After-course. — The  wonnd  healed  promptly.  Three  weeks  later  the 
skin  along  the  edges  of  the  wound  was  reddened.  In  an  additional 
three  weeks  the  skin  had  a  hard  brawny  feel  and  the  redness  had 
become  more  pronounced  (Fig.  163-5).  The  reddened  area  was  cut 
out  and  the  wound  left  wide  open.     The  intensive  use  of  the  x-raj^ 


■  /ft       -y         *  "< 


Fig.    163-C — Slide   from   the  specimen    shown   in   the   preceding   figure.      The   cancer   cells   are 
scattered    diffusely   and   in   some    areas   present   a   true    lymphangitis    carcinomatosa. 

was  begun  in  the  widely  open  wound.  The  wound  began  to  heal, 
but  in  two  months  there  were  multiple  nodules  in  the  skin  of  the 
chest.  The  slide  of  the  skin  recurrence  shows  a  diffuse  dispersion  of 
the  tumor  cells  (Fig.  163-C).  The  term  lymphangitis  carcinomatosa 
may  well  be  applied  to  it. 

Comment. — Wlienever  the  skin  over  a  diffuse  carcinoma  of  the 
breast  is  reddened,  am^  sort  of  treatment  is  utterly  futile  and  can 
but  bring  disaster  to  the  patient  and  chagrin  to  the  surgeon.     In 


DISEASES    OF    THE    BREAST  339 

large  glandular  carcinomas  the  skin  may  become  invadecl  and  the 
prognosis  yet  be  fair,  bnt  these  must  be  separated  from  the  above 
type.  Such  cases  had  best  be  sent  at  once  to  the  roentgenologist.  It 
is  not  to  be  expected  that  he  will  do  any  particular  good,  but  at 
least  his  efforts  will  do  no  harm. 

DIFFUSE  AFFECTIONS  OF  THE  BREAST 

In  diffuse  affections  of  the  breast  one  usually  thinks  of  an  inter- 
stitial mastitis  or  a  senile  pareneh^Tnatous  hypertrophy.  If  there 
is  any  sense  of  discomfort  or  if  there  are  any  palpable  bosselations 
one  thinks  of  malignancy.  If  these  areas  are  dense,  of  irregular 
border,  particularly  if  there  is  fixation  of  the  skin  or  nipple,  ma- 
lignancy is  probable.  Inspection  through  an  incision  alone  can  de- 
termine the  facts.  This  x>roblem  tests  the  acumen  of  the  surgeon 
more  than  any  other  in  tumor  surgery. 

CASE  1. — A  childless  married  woman  of  thirty  came  to  the  hos- 
pital because  of  an  affection  of  both  breasts. 

History. — The  patient  has  had  trouble  with  both  breasts  a  year. 
She  thinks  she  can  feel  a  tumor  in  each.  Her  physician  has  con- 
firmed this.  The}"  get  sore  before  menstruation  and  sometimes  are 
painful  at  other  times.  Now  she  has  pain  in  the  chest  as  well.  The 
menses  are  scant  and  are  becoming  more  so.  the  flow  lasting  but  a 
day  or  so.  She  has  a  good  deal  of  pain  in  the  lower  abdominal  re- 
gion, particularly  the  last  half  day  of  her  period,  which  often  com- 
pels her  to  go  to  bed.  Bowels  are  regular.  There  is  no  leucorrhea. 
The  patient  is  emphatically  stout,  having  passed  the  two  hundred 
mark  some  time  before  this  estimate  was  made.  The  patient  volun- 
teers the  information  that  a  sister  had  a  similar  complaint  for  which 
a  double  amputation  was  done.  This  sister,  she  states,  on  inquiry, 
is  like  herself,  decidedly  plump,  and  suffers  from  a  progressively 
diminishing  menstrual  flow.  The  patient  has  been  advised  to  have  a 
double  amputation  done. 

Examination. — The  breasts  represent  huge  masses  of  fat  of  uni- 
form consistency  and  form.  Large  lobules  of  fat  can  be  made  out, 
particularly  near  the  axillary  border.  It  is  these  masses  which  were 
regarded  as  tumors.  There  is  no  suggestion  of  retraction  of  the 
nipple  or  limitation  of  motion  of  the  skin  anywhere. 


340  CLINICAL    SURGERY    BY    CASE    HISTORIES 

Pidfjiiosis. — Nothing'  l)ii1  fa1ty  masses  can  1)0  made  ont.  These 
breasts  present  some  interstitial  mastitis,  but  these  bundles  are  quite 
lost  in  the  huo-e  masses  of  fat.  The  excessive  adiposity  associated 
with  diminishing  antl  ]niinful  menstruation  represents  some  dis- 
turbance of  the  ductless  gland  system.  There  is  an  associated  meno- 
pause usually.     The  breasts  are  but  a  secondary  process  to  this. 

Treatment. — Operation  not  indicated.  No  treatment  seems  to  do 
these  i)atients  any  good  bnt  this  one  was  given  luteal  extract,  more 
to  keep  her  under  observation  until  she  should  lose  her  desire  for 
operation  than  from  any  hope  of  benefit  from  the  treatnumt. 

After-course. — The  menses  gradually  diminished  and  have  now 
been  absent  nine  months  with  a  corresponding  cessation  of  the  pains 
in  the  breast.     She  is  content  with  her  lot. 

Coniineiit. — Progressive  gain  in  weight  associated  with  diminished 
painful  menstruation  particularly  menstruation  that  is  painful  at 
its  termination  is  associated  with  precocious  atrophy  of  the  ovary 
and  often  results  in  i^remature  menopause.  These  patients  often 
complain  of  pain  in  the  breasts.  The  breast  changes  are  confined 
to  an  increase  in  the  fibrous  tissue.  To  remove  such  breasts  is  to 
subscribe  to  the  dictum  "when  in  d()ul)t,  operate,"  with  a  vengeance. 

CASE  2. — A  matron  aged  thirty-seven  came  because  of  an  uncom- 
fortable fullness  of  both  breasts. 

His'orij. — The  patient  is  a  wel]-develoj)ed  woman  with  an  enei'getic, 
nervous  manner.  Both  breasts  feel  thick  and  full  to  the  Hat  hand. 
No  nodulations  can  be  separated  out,  but  there  is  some  general  un- 
evenness  of  the  surface.  The  skin  is  free  and  the  breasts  move  freely 
over  the  underlying  structures.  The  nipples  are  not  attached  or  re- 
tracted. 

Diaguosis. — Though  no  definite  areas  of  malignancy  can  l)e  de- 
tected, because  of  the  marked  general  thickening  a  satisfactory  pal- 
pation is  not  possible.  The  general  roughened  surface  indicates  a 
cystic  state  and  the  elasticity  of  the  intervening  tissue  presents  the 
rubber-like   elasticity   of   interstitial   mastitis. 

Treatiiioit. — Because  of  the  extensive  area  involved  and  the  unusual 
density  of  the  tissue  it  was  felt  that  all  areas  might  not  be  suffi- 
ciently explored,  and  because  the  patient's  physician  thought  a  double 
amputation  should  be  done,  this  plan  was  followed. 

Patliologij. — The  mass  is  made  up  of  dense  fibrous  tissue  with  a  few 


DISEASES    OF    THE   BREAST 


341 


Fig.    164. — Interstitial    mastitis  with    cysts. 


Fig.    165. — Interstitial   mastitis   with   slight   cyst   proliferation 


342  CLINICAL   SURGERY   BY    CASE    HISTORIES 

small  CA^sts  (Fig.  164).  No  area  of  malignancy  was  found,  but  the 
cells  of  the  acini  are  larger  than  normal  and  in  some  of  the  outlet 
ducts  show  a  piling  up  of  the  epithelium  (Fig.  165). 

After-course. — The  patient  is  free  from  disturbance  three  years 
after  operation. 

Comment. — The  operation  was  purely  a  prophylactic  one.  The 
indications  given  were  wrong  on  both  counts.  A  sufficient  operating 
exploration  would  have  been  adequate  and  the  desire  of  the  attend- 
ing physician  was  not  of  sufficient  weight  to  have  warranted  a  modi- 
fication of  judgment.  On  the  other  hand  the  breast  was  so  exten- 
sively involved  that  which  portion  to  excise  was  difficult  to  deter- 
mine. However,  this  should  have  been  done.  A  well-formed  breast 
could  have  been  left.  A  suspicion  is  never  an  adequate  excuse  for 
operation,  for  "suspicious"  cases  are  inversely  proportional  to  the 
diagnostic  acumen  of  the  clinician. 

CASE  3. — A  housewife  aged  thirty-seven  comes  because  of  a  tu- 
mor of  her  breast. 

History. — The  patient  has  had  two  children.  She  nursed  both  of 
them  without  incident.  Three  months  ago  she  began  to  notice  a 
dull  pain  in  the  left  breast.  It  has  not  increased  since  that  time. 
She  discovered  a  tumor  after  the  first  sensations  of  pain  were  felt. 
The  discomfort  is  most  marked  just  before  the  menstrual  period. 
She  has  been  advised  to  have  a  radical  operation  done  "to  be  sure," 
but  having  pride  in  her  personal  appearance,  she  regards  such  a  con- 
tingency but  little  better  than  a  fatal  carcinoma. 

Examination. — The  patient  is  a  well-developed  woman  of  excellent 
general  health.  The  breasts  are  symmetrical  and  neither  shows  ab- 
normalities. The  fiat  hand  does  not  reveal  any  tumors  in  either 
breast.  By  picking  up  the  breasts  between  the  thumb  and  fingers 
the  mass  is  found  to  be  increased.  At  the  site  complained  of  the 
thickening  was  perhaps  a  little  more  pronounced.  There  was  no 
limitation  or  dimpling  of  the  skin  or  retraction  of  the  nipple. 

Diagnosis. — The  general  thickening  is  that  of  interstitial  mastitis. 
There  is  no  evidence  of  malignancy.  The  relation  of  the  skin  to  the 
mass  beneath  was  carefully  tested  out,  both  b}-  manipulation  and 
by  changing  the  position  of  the  patient.  Both  breasts  being  almost 
equally  affected  lessens  the  likelihood  of  malignancy.     Since  a  small 


DISEASES    OF    THE    BREAST 


343 


malignant  focus  deeply  situated  can  not  be  excluded,  a  diagnostic 
incision  is  advised. 

Treatment.— An  elliptical  incision  was  made  along  the  upper  mar- 
gin of  tlie  chief  thickening.  The  suspected  area  was  incised  in 
various  directions,  but  no  suspicious  areas  were  found.  The  tissue 
everywhere  was  elastic,  both  to  the  feel  and  to  the  knife. 

Pathology. — On  section  the   cut   surface   is  mottled  with   pinkish 


Fig.   166. — Section  of  interstitial  mastitis. 

white  and  fatt}"  tissue  (Fig.  166).  In  some  areas  grayish  white 
dots  can  be  seen.  These  dots  are  seen  on  section  to  be  the  ducts  with 
some  proliferation  of  the  walls  (Fig.  167).  The  homogenous  tissue 
is  fibrillar  elastic  tissue  in  astonishingly  large  amounts. 

After-course. — Recovery  was  uneventful  and  has  been  permanent. 

Comment. — This  type  of  breast  trouble  is  most  diificult  of  all 
lesions  to  differentiate  with  certainty  from  malignancy.  One  can  be 
sure  only  that  that  part  of  the  breast  which  is  incised  is  free  from 


344 


CLINICAL    SUKUERY    BY    CASK    HISTORIES 


inalionancy.  Yet  one  does  not  want  to  nintilate  a  large  number  of 
women  in  ordcn-  to  give  a  slightly  iiiri'cascd  chance  for  the  few  which 
do  show  malignancy.  It  has  Ijecn  my  experience  that  i)liim|i  women, 
before  the  menopause,  with  large  breasts  invariably  have  recurrence. 


Fig.     167. — Interstitial    mastitis.      A.  Area     of    fibrous    tissue    without    cells.      B.   Duct    with 

proliferating  epithelium. 

no  matter  how  early  the  operation  or  how  radical.  To  operate  on 
many  who  do  not  have  malignancy  to  be  sure  of  operating  early  the 
few  that  do  have  is  too  much  like  rejoicing  over  the  one  gone  astray 
and  disregarding  the  ninety  and  nine  innocent.  That  may  be  good 
theology,  but  it  is  poor  conservative  surgery. 

CASE  4. — A  man  aged  eighteen  came  because  of  a  growth  in  his 
left  breast. 

History. — The  patient  has  always  had  good  health.  Four  months 
ago  he  had  some  pain   in  the  left   l)reast  and  some  thickening  de- 


DISEASES    OF    THE    BREAST 


345 


veloped.  This  increased  to  a  certain  degree  and  then  remained  sta- 
tionary. He  has  consulted  a  surgeon  and  a  dermatologist  both  of 
whom  diagnosed  cancer  and  advised  radical  operation. 

Examination. — There  is  a  hard  disc   occupying  the  whole  of  the 
diminutive  breast.     It   is  as  though  the  whole  breast  had  been  in- 


Fiar.   168. — Interstitial  mastitis. 


■V^ 


^»« 


Fig.    169. — Interstitial    mastitis   with    deeply   staining   epithelium. 


filtrated  with  paraffin.  The  skin  is  freely  movable  over  the  breast, 
and  the  breast  moves  freely  over  the  underlying  tissue.  The  breast 
gives  the  sensation  of  a  huge  hard  chancre. 

Diagnosis. — The  elasticity  and  extent  stamp  it  as  an  interstitial 
mastitis. 

Treatment. — The  patient  was  thoroughly  alarmed  by  his  previous 


346  CLINICAL   SURGERY   BY    CASE    HISTORIES 

consultants  and  he  strongly  desired  operation.  Enucleation  of  the 
whole  gland  was  done. 

PatJiology. — On  section  the  breast  is  made  up  of  radiating  bundles 
of  fibers.  These  interlace  in  the  body  of  the  gland  and  radiate  to 
the  nipple  (Fig.  168).  It  is  everywhere  elastic.  Microscopically  there 
is  much  increase  in  the  interstitial  tissue,  and  some  increased  tinc- 
torial reaction  of  the  cells  to  basic  dyes  but  they  are  nowhere  in- 
creased in  number  (Fig.  169). 

After-course. — The  patient  has  remained  well. 

Comment. — These  interstitial  mastitides  in  boys  are  by  no  means 
rare,  and  if  unmolested,  disappear  spontaneously  in  the  course  of  three 
to  six  or  more  months.  Excision  is  justified  only  to  prevent  some 
one  from  doing  a  more  radical  operation.  In  middle-aged  males 
excision  should  be  the  rule.  Local  excision  cures  them.  Sometimes 
these  show  duct  epithelium  that  is  prominent  and  deeply  staining 
but  I  have  never  seen  one  invading  the  surrounding  tissue  or  recur- 
ring after  local  removal.  Most  of  the  cases  at  least  recorded  as  car- 
cinoma in  the  male  belong  to  this  class. 

CASE  5. — A  maiden  lady  aged  thirty-eight  came  to  me  because 
of  peculiar  stinging-  pains  in  the  rig^ht  breast. 

History. — She  had  menstrual  disturbance  her  whole  life,  but  other- 
wise has  had  no  special  complaints.  She  has  had  pain  in  the  breasts 
at  each  period  as  long  as  she  can  remember.  Recently  she  has  had 
stinging  pain  in  the  right  breast  at  times  other  than  the  menstrual 
period.     She  locates  the  offending  area  lateral  to  the  nipple. 

Examination. — The  patient  is  tall  and  slender  with  sallow  complex- 
ion and  apprehensive  look.  The  breasts  small  and  flat.  General 
irregularities  are  palpable  in  both  breasts  with  the  finger  tips.  Lat 
eral  to  the  left  nipple  is  a  small  area  harder  than  the  surrounding 
nodules.  In  the  right  breast,  the  one  complained  of,  there  are  no 
areas  more  conspicuous  than  others.  The  area  complained  of  shows 
no  palpable  mass.    There  are  no  retractions  of  the  skin  or  nipple. 

Diagnosis. — The  history  of  irritation  of  the  breasts  at  the  menstrual 
period  associated  wdth  a  dysmenorrhea  in  a  neurotic  subject  suggests 
an  interstitial  mastitis.  The  presence  of  very  small  nodules  in- 
dicates an  associated  cystic  degeneration.  None  of  these  nodules 
are  irregular  and  there  is  no  fixation  of  the  skin.  The  only  factor 
suggesting  malignancy  is  the  recent  appearance  of  stinging  pain  in  the 


DISEASES    OF    THE    BREAST  347 

breast  between  the  periods.  This  indicates  that  there  is  some  process 
active  enough  to  produce  an  intermenstrual  pain.  A  developing 
cyst  sometimes  produces  a  sense  of  uncomfortable  fullness,  less  often 
of  stinging  discomfort.  Stinging  pain  on  the  other  hand,  particu- 
larly if  intermenstrual  is  often  the  first  evidence  of  malignancy. 

Treatment. — It  was  proposed  to  the  patient  to  explore  the  breast, 
and  should  a  malignant  area  be  found  the  radical  operation  would  be 
performed.  The  breast  was  exposed  and  after  numerous  incisions 
had  been  made,  a  small  area  in  the  outer  upper  quadrant  was  dis- 
covered which  cut  readily  and  showed  a  pink  area  clotted  with  small 


Fig.    170. — Interstitial  breast   with   small   malignant   area. 

greyish  points  (Fig.  170).  This  area  felt  hard  to  the  touch.  Radical 
operation,  therefore,  was  performed. 

Pathology. — The  diminutive  breast  shows  many  small  patches  of 
interstitial  mastitis,  and  but  one  tiny  patch  that  is  more  dense  than 
the  surrounding  patches  as  noted  at  the  operation.  There  were  no 
cysts  in  the  interstitial  tissue.  A  few  of  the  acini  were  filled  with 
cells  which  showed  no  invasion  of  the  surrounding  tissue,  however. 
The  area  in  question  showed  definite  invasion  of  the  surrounding  tis- 
sue.    The  axillary  contents  presented  no  affected  glands. 

After-course. — The  patient  was  free  from  recurrence  five  years 
after  operation. 

Comment. — This  tjjie  of  person  rarely  has  malignancy  follow  in- 
terstitial mastitis.  Onh^  by  incision  could  the  malignant  area  be 
discovered.     Careful  search  of  such  breasts  must  be  made  lest  small 


348  CLINICAL    SURGERY    BY    CASE    HISTORIES 

areas  be  overlooked.  T  liave  sten  sucli  breasts  harbor  areas  of  malig- 
nancy no  larper  than  a  grain  of  wheat.  This  is  the  type  in  which 
a  diagnosis  by  tlic  microscopist  often  leads  to  error,  becanse  the  in- 
volved area  is  missed  and  the  ])athologi.st  can  diagnose  only  wluit 
he  sees. 

CASE  6. — A  housewife  aged  forty-six  came  to  me  because  of  a 
slight  pain  in  her  right  breast. 

History. — The  patient  has  had  no  children.  For  a  year  and  a  half 
she  has  had  a  fullness  of  both  breasts  and  for  the  past  few  weeks  has 
iiad  slight  pain  in  the  right  one.  Her  health  has  always  been  ex- 
cellent. 

E.raniiiKtfioit. — The  patient  is  a  large,  stately  woman  with  well- 
formed  lii'casts.  Xo  tumor  is  palpable  in  either  b.reast  wilh  tlie 
fhit  hand.  Fingi'i-  paljiaticn  shows  a  small  round  nodule  at  the 
outer  border  of  tlie  right  breast  near  the  border  of  the  pectoralis 
majoi-.  It  se-.'ms  to  be  circumscribed  l;ut  does  not  glide  under  the 
finger.  The  remainder  of  the  glaiul  is  thick  and  firm,  but  somewhat 
elastic.  Over  the  nodule  al)ove  mentioned  the  skin  is  less  freely 
moval)le  than  over  the  remainder  of  the  breast.  AVIkmi  the  patient  is 
turned  on  the  left  side  the  skin  (linr,)Ies  at  this  point.  The  left 
breast  likewise  is  much  thickened  t)Ul  w  itliout  localized  tumefaction 
and  without  involvement  cf  the  skin. 

Diagnosis. — Th.c  indefinite  tumor  and  llie  limitation  of  movement 
of  the  skin  suggests  malignancy  and  th(>  dimpling  on  change  of  posi- 
tion well  nigh  proves  it  so.  The  remainder  of  the  breast,  as  well  as 
the  o]iposite  breast,  is  evidently  involved  in  a  marked  interstitial 
mastitis.  ^Marked  mastitis  in  a  woman  of  this  build  is  always  an  ob- 
ject of  deep  a]iprehension. 

Trraf)ur)if. — Pi'eliniiuary  diagnostic  incision  showed  the  suspected 
area  to  be  a  cyst  with  a  small  area  of  malignancy  just  below  it. 
A  radical  removal  was  done.  There  were  no  enlarged  glands  in  the 
axillary  tissue  removed.  The  left  breast  showed  as  extensive  inter- 
stitial mastitis  as  the  right,  but  no  malignancy.  The  patient  wished 
that  if  one  breast  required  removal,  the  other  be  removed  also.  She 
explained  that  her  esthetic  problems  could  be  more  easily  solved  if 
both  breasts  were  removed  than  if  she  were  deprived  of  one  and 
retained  the  other.     The  left  breast  was,  therefore,  removed. 

Pathology. — The  right  breast  showed  a  cyst  the  size  of  a  hickory 
nut  and  above  it  a  small  area  of  malignancy  (Fig.  171).     It  was  this 


DISEASES    OF    THE    BREAST 


349 


I'ig.    171. — Carcinoma    in   inteistitial    mastitis    of   breast. 


350  CLINICAL   SURGERr   BY    CASE    HISTORIES 

cyst  and  not  the  malignant  area  that  was  palpable.  The  skin  fixation, 
however,  was  due  to  the  retraction  of  the  malignant  area.  This  area 
shows  unusually  well  the  fine  grayish  white  cancer  nests  contrasted 
with  the  pinker  connective  tissue.  It  is  the  density  to  touch,  and  the 
ease  with  which  it  yields  to  the  knife,  in  comparison  to  the  more 
rubber-like  consistency  of  the  interstitial  mastitic  areas,  that  particu- 
larly characterize  the  malignant  area.  The  remainder  of  the  breast 
shows  mastitic  patches  with  large  intervening  lobules  of  fat. 

After-course. — A  year  and  a  half  after  the  operation  she  began 
to  have  sjTnptoms  of  mediastinal  involvement  and  died  at  the  end 
of  another  six  months  under  symptoms  of  mediastinal  compression. 
There  was  no  local  or  glandular  metastasis. 

C omment .—Young  women  or  those  at  or  about  the  menopause  who 
have  large,  well-formed  breasts  give  a  bad  prognosis.  The  reason 
for  this  is  not  clear.  This  type  of  person  with  patchy  interstitial 
mastitis  should  be  subjected  to  resection  of  the  involved  area  and  if 
malignant  areas  are  discovered  radical  operation  should  be  done.  The 
prognosis  is  exceedingly  bad  in  such  cases,  no  matter  how  early,  ap- 
parently, the  operation,  or  how  radically  it  is  done. 

ENCAPSULATED  TUMORS  OF  THE  BREAST 

If  a  tumor  of  the  breast  is  encapsulated,  it  is  but  a  simple  matter 
of  local  excision.  It  is  either  a  simple  fibroadenoma  or  an  intra- 
canaliculary  fibro-adenoma.  One  need  only  to  keep  in  mental  re- 
serve that  in  rare  instances  do  these  tumors  develop  malignancy. 
If  the  epithelial  elements  become  malignant,  small,  hard  elevations 
appear  at  some  part  of  the  surface.  If  the  fibrous  elements  become 
malignant,  a  rapidly  enlarging  expansile   tumor  results. 

CASE  1. — A  school  teacher  aged  twenty-four  came  to  the  hospital 
because  of  a  tumor  of  the  breast. 

History. — She  noticed  a  tumor  in  her  left  breast  about  a  year  ago. 
The  discovery  was  accidental,  for  it  has  given  her  no  trouble,  and 
she  has  noticed  no  change  in  the  tumor  since  it  was  first  discovered. 
There  never  has  been  any  trouble  in  that  breast  that  she  can  re- 
member. Save  for  a  slight  pain  at  the  beginning  of  menstruation  her 
health  is  uniformly  good. 

Examination. — There  is  a  hard,  freely  movable,  sharply  defined 
tumor,  the  size  of  a  walnut  in  the  upper  outer  quadrant  of  the  left 


DISEASES    OF    THE   BREAST 


351 


breast.  The  surface  contains  a  number  of  low  bosselations.  These 
are  not  attached  to  the  surrounding  tissue.  The  whole  mass  is  dense 
and  elastic. 

Diagnosis. — The  innocent  nature  of  the  tumor  is  apparent  from  the 
lack  of  discomfort  and  from  its  mobility.  The  irregular  bosselated 
surface  distinguishes  it  as  an  intercanaliculary  fiber  adenoma  instead 
of  a  simple  fibroadenoma,  the  latter  being  characterized  by  a  smooth 
surface  free  from  bosselations.  The  question  of  secondary  malig- 
nancy is  decided  in  the  negative  because  none  of  the  bosselations  are 


A.  B. 

Fig.    172. — ;Mixed  tumor  of  the  breast.     A.  External  surface.     B.   Cross   section. 

hard  and  adherent  as  they  would  be  were  there  any  malignant  pro- 
cesses going  on. 

Treatment. — The  tumor  with  its  capsule  was  removed  under  local 
anesthesia. 

PatJiology. — The  gross  appearance  presents  a  surface  smooth  but 
with  many  secondary  nodules  (Fig.  172).  The  cut  surface  presents 
a  clear  white  plane  wdth  fine  fissures  and  little  nodules  here  and 
there.  The  slide  shows  an  abundance  of  fibrous  tissue  with  various 
sized  cavities  filled  wuth  developing  fibrous  tissue  (Fig.  173). 

After-course. — Recovery  was  permanent. 

Comment. — The  intercanaliculary  fibroadenomas  rarely  become  ma- 


352 


CLINICAL    SURGERY   BY    CASE    HISTORIES 


lignant  throiiph  epithelial  development.  When  tliey  do  manifest  malig- 
nant growth  it  is  the  fibrous  tissue  elements.  There  is  no  sharp  line 
of  separation  between  these  tumors  and  the  typical  fibroadenomas.  Jii 
fact  it  is  not  uneonnnon  to  find  tumors  representing  each  type  of 
tumor.  In  rarer  cases  cartilage  is  found  in  them  and  quite  com- 
monly myxoid  tissue  is  observed.  These  factors  bring  them  into 
close  relationshi]!  to  the  mixed  tumors.  This  relationshiji  is  further 
emphasized  by  their  course  when  they  take  on  rapid  growth.  Though 
they  may  become  cellular,  they  show  a  very  low  malignancy,  little 


Fig.    173. — Slide   of  mixed   tumor  of  the   Iireast.      ( Filiroadeiioma   intracanaliculary. ) 

deserving  the  term,  sarcoma,  u.sually  applied  to  them  when  they 
reach  this  state.  "Mixed  tumors"  is  a  term  that  at  once  covers  their 
varjung  structure  as  well  as  tlieir  clinical  behavior.  Local  excision 
together  with  the  caiisuli'  which  contains  them  is  sufficient  to  bring 
about  a  radical  cure. 

CASE  2. — A  doctor  aged  twenty-four  came  because  of  a  tumor  of 
his  breast. 

Historij. — For  tliree  months  the  patient  has  been  annoyed  by  a  grad- 
ually developing  tumor  beneath  the  left  nipple.  There  has  been  no 
actual  pain,  but  he  has  been  conscious  of  its  presence. 

Examinaiion. — A  flat  mass  an  inch  and  a  half  in  diameter  and 
half  an  inch  lliick  lies  in  the  center  of  the  breast.     It  is  dense,  some- 


DISEASES    OF    THE    BREAST 


353 


what  bosselatecl  and  not  completely  encapsulated,  yet  not  closely  at- 
tached to  the  surrounding  tissue.  The  breast  about  the  tumor  seems 
free.    The  nipple  is  not  involved. 

Diagnosis. — The  general  physical  characteristics  suggest  intercan- 


Fig.    174. — A  gross  appearance   of   intracanaliculary  tumor  of   the  male. 


'i^ 


'>«C^ 


Fig.    175. — Epithelial  proliferation   of  the   ducts. 

alicular  fibroadenoma.  It  is  more  closely  attached  to  the  surround- 
ing tissue  than  is  usual  in  this  type  of  tumor  and  the  situation  just 
beneath  the  nipple  is  unusual.  On  the  contrary,  the  pad-like  shape 
of  the  tumor  and  its  situation,  together  with  its  relation  to  the  sur- 
rounding tissue  suggests  an  interstitial  mastitis.     It  has  no  definite 


354  CLINICAL   SURGERY    BY    CASE    HISTORIES 

attachment  to  the  skin,  neither  is  there  fixation  and  retraction  of  the 
nipple,  nor  is  the  age  that  common  in  carcinoma. 

Treatment. — The  tumor  was  resected  together  with  the  tissue  im- 
mediately attached  to  it. 

Pathology. — The  surface  is  irregular  and  is  adherent  to  its  capsule 
(Fig.  174).  The  cut  surface  is  dense  and  fibrous,  pink  in  color,  with 
very  fine  white  dots.  These  dots  on  section  are  seen  to  be  ducts  with 
somewhat  hypertrophied  epithelium.  The  connective  tissue  is  much  in- 
creased and  cellular.  The  duct  glands  nowhere  escape  their  normal 
boundaries  though  there  is  some  plasma  cell  infiltration  about  the 
basement  membrane  (Fig.  175). 

After-course. — The  breast  has  remained  free  from  recurrence  after 
six  years. 

Comment. — These  growths  seem  closelj'  allied  to  interstitial  masti- 
tis often  observed  in  young  males.  Their  course  is  that  of  a  mastitis 
though  the  microscopic  picture  gives  no  evidence  of  an  inflammatory 
reaction.  The  change  is  that  of  a  connective  tissue  hypertrophy. 
These  tumors  when  locallj^  removed  do  not  recur,  but  when  left  alone 
do  not  disappear  spontaneously  as  the  interstitial  mastitis  in  young 
males  does.  These  are  usually  called  duct  cancer  of  the  male.  There 
is  little  evidence  that  they  become  malignant.  I  have  done  a  con- 
servative operation  on  a  goodly  number  of  these  without  recurrence. 

CASE  3. — A  maiden  governess  aged  forty-six  came  to  the  hospital 
because  of  a  huge  tumor  of  the  breast. 

History. — A  nodule  was  first  noted  in  her  left  breast  five  years 
ago.  It  grew  slowly  until  last  summer,  when  it  began  to  grow  rapidly. 
It  has  not  been  painful.    Her  general  health  has  always  been  good. 

Examination. — A  nodulated,  bosselated  tumor  the  size  of  an  adult 
head  occupies  the  site  of  the  left  breast.  It  is  fairly  firm,  but  elastic, 
particularly  in  certain  rather  indefinite  areas.  The  axillary  glands 
are  free  and  the  tumor  glides  freely  over  the  fascia.  The  tumor  has 
ulcerated  through  the  skin  over  an  area  the  size  of  a  watch.  The  skin 
is  unattached  to  the  tumor  either  about  the  ulcerated  area  or  else- 
where. The  nipple  rides  high  on  the  surface  of  the  tumor  reminding 
one  of  a  dimiinitive  steeple  of  a  village  church.  The  skin  is  obviously 
destroyed  by  pressure  erosion  and  not  by  infiltration. 

Diagnosis. — The  huge  size,  its  bosselated  exterior  and  the  manner 
of  destroying  the  skin  stamps  it  as  a  mixed  tumor.    Its  rapid  growth 


DISEASES    OF    THE    BREAST 


355 


Fig.    176. — Mixed  tumor  of  the  breast    (so-called   cystic   sarcoma). 


356 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


^^r'^^^^^^R 

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M 

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M- 

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dr   • 

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iuM 

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JjMH 

■k 

\ 

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mild 

Jk^.        -^^^b 

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Fig.   178. — Encapsulated  carcinoma  of  the  breast. 


DISEASES    OF    THE   BREAST  357 

indicates  that  the  connective  tissue  elements  have  taken  on  a  marked 
proliferation.  When  this  state  exists,  the  tumors  are  sometimes  called 
sarcomas,  a  cognomen  their  history  justifies  but  it  is  not  borne  out 
by  their  clinical  behavior. 

Treatment. — The  tumor  was  removed  by  a  colleague  who,  fearing 
possible  glandular  metastasis,  cleared  out  the  axillary  space  also. 

Pathology. — The  tumor  is  made  up  of  a  pinkish  white  material 
showing  a  disposition  to  wave  formation  (Fig.  176).  This  is  inter- 
spersed with  numerous  cysts.  In  certain  areas  distinct  cj'sts  are  seen. 
In  structure  the  bulk  of  the  tumor  consists  of  mixed  cells  (Fig. 
m-A)  with  equally  extensive  areas  in  which  bundles  of  fibers  with 
small  nuclei  are  found  (Fig.  177-5). 

After-course. — The  patient  has  remained  well. 

Comment. — These  tumors  when  they  grow  rapidly  are  very  omi- 
nous affairs.  However,  they  are  expansile  in  growth  and  seem  never 
to  invade  surrounding  tissue  or  to  form  metastasis.  Local  removal 
is  all  that  is  required.  I  have  never  seen  a  recurrence  after  such 
treatment.  The  capsule  should  be  removed  along  with  the  tumor, 
and  not  merely  the  tumor  shelled  out. 

CASE  4. — A  matron  aged  fifty-six  came  for  consultation  because 
of  a  painless  tumor  of  the  breast. 

History. — The  patient  has  had  six  children  all  of  whom  she  nursed 
without  disturbance  of  the  breasts.  Six  months  ago  she  noticed  a 
tumor  of  the  left  breast.  It  was  as  large  as  a  hen's  egg  when  she 
first  noticed  it.  She  thinks  it  must  have  come  suddenly  or  she  would 
have  observed  it  earlier.  It  has  caused  no  pain  and  she  seeks  advice 
only  at  the  earnest  solicitation  of  her  family.  She  passed  the  meno- 
pause eight  years  ago  and  her  health  is  good  in  every  way. 

Examination. — The  patient  is  well-nourished  and  has  well-developed 
mamniffi.  A  prominence  is  visible  in  the  left  breast  in  the  upper  outer 
quadrant.  On  palpation  a  tumor  the  size  of  an  egg  is  easily  palpa- 
ble. It  is  spherical  and  rolls  freely  under  the  examining  fingers.  On 
closer  examination  it  is  seen  that  the  encapsulation  is  only  apparent. 
The  skin  can  not  be  lifted  from  the  tumor,  neither  can  the  gland  be 
slid  over  the  surface  of  the  tumor.  The  tumor  is  hard  and  fine 
granular  bossellations  can  be  felt  here  and  there  over  the  surface  of 
the  tumor.  Firm  pressure  causes  slight  pain.  There  are  no  palpable 
glands. 


358  CLINICAL   SURGERY   BY    CASE    HISTORIES 

Diagnosis. — The  density  and  pseudoencapsulation  stamp  this  tu- 
mor as  a  carcinoma.  It  resembles  most  closely  a  mixed  tumor  of  the 
fibroadenoma  in  general  outline,  while  the  consistency  suggests  ma- 
lignancy. Mixed  tumors  rarely  appear  as  late  in  life,  are  more 
elastic,  and  less  painful  on  pressure  and  the  encapsulation  is  definite. 
Mixed  tumors  sometime  show  small  bossellations  but  they  are  elastic 
and  do  not  stick  out  into  the  surrounding  tissues  as  malignant  ones 
do. 

Treatment. — Radical  operation  was  done. 

Pathology. — The  section  of  the  tumor  shows  a  fine  granular  sur- 
face, uniform  throughout  the  tumor  (Fig.  178).  This  slide  shows  it 
to  be  an  adenocarcinoma. 

After-course. — The  patient  is  free  from  recurrence  after  five  years. 

Comment. — These  tumors  usually  occur  in  the  breasts  of  women 
after  the  menopause  and  follow  a  rapid,  painless  course.  They  ini- 
tiate an  expansile  growth  and  are  the  least  malignant  of  the  breast 
carcinomas  despite  their  rapid  growth.  Their  low  malignancy  is 
due  to  the  fact  that  they  retain  an  adenoid  structure.  This  accounts 
for  their  relatively  slight  disposition  to  meta.stasize.  This  is  the 
type  that  grows  to  large  size  and  eventually  ulcerates  through  the 
skin. 

CYSTIC  TUMORS  OF  THE  BREAST 

Cysts  in  the  breast  are  usually  retention  affairs  due  to  occlusion 
of  the  ducts  by  proliferated  interstitial  tissue.  These  not  infrequently 
show  proliferations  in  their  interior,  which  are  sometimes  maligiuint. 
On  the  other  hand,  malignancies  sometimes  show  broken-down  inte- 
riors. When  a  cyst  is  discovered  in  the  breast,  the  interior  must  be 
inspected. 

CASE  1. — A  matron  of  forty-six  came  because  of  a  tumor  of  the 
breast. 

History. — The  patient  has  noticed  a  small  tumor  of  the  breast  for 
six  months.  It  has  caused  some  stinging  and  uneasiness  but  no  real 
pain. 

Examination. — The  patient  is  tall,  thin  and  nervous.  Lateral  to 
the  left  nipple  is  a  rounded  mass  the  size  of  a  hickory  nut.  The 
breast  in  this  region  is  thickened.  The  nodule  is  smooth  and  glides 
about  under  the  finger  tips. 


DISEASES    OF    THE   BREAST 


359 


Diagnosis. — The  physical  character  of  the  mass  suggests  a  cyst  and 
the  bordering  tissue  is  elastic  and  there  is  no  attachment  to  the 
skin. 

Treatment. — The  cyst  and  the  thickened  tissue  were  resected. 

Fatliology. — The  cyst  is  attached  to  the  breast  tissue  at  one  pole 


Fig.    179. — Cyst   in   an   interstitial   mastitis. 

(Fig.  179).  The  cyst  was  lined  with  a  simple  epithelium.  The  sur- 
rounding tissue  presents  a  simple  interstitial  mastitis. 

After-course. — Recovery  has  been  permanent. 

Comment. — This  type  of  person  is  the  normal  habitat  of  cystic 
mammse.  Resection  is  attended  with  less  risk  of  missing  a  malignant 
area  than  in  a  breast  of  the  same  physical  characters  in  a  better  nour- 
ished patient. 

CASE  2. — A  maiden  school  teacher  aged  forty-six  came  because 
of  a  tumor  of  the  breast. 

History. — Maiden  school  teacher  of  good  general  health.  She  has 
noticed  a  tumor  of  the  breast  for  four  months.  She  has  put  off  seek- 
ing relief  until  she  should  finish  the  school  year.  She  has  no  actual 
pain  but  there  is  a  sense  of  fullness  which  is  worse  just  before  and 
during  the  first  few  days  of  menstruation.  Her  nervous  system 
shows  the  effects  of  twentv-five  vears  of  the  school  room. 


360  CLINICAL   SURGERY   BY    CASE    HISTORIES 

Examination. — The  flat  hand  shows  a  tumor  the  size  of  a  hulled 
walnut  just  above  and  external  to  the  nipple.  There  are  smaller 
nodules  lateral  to  the  main  tumor.  The  larger  tumor  is  smooth 
and  elastic.  The  breast  tissue  surrounding  it  is  not  much  thickened. 
The  opposite  breast  shows  fine  round  nodulation.  likewise  without 
notable  interstitial  thickening. 


Fig.    ISO. — Cystic   breast 


Diagnosis. — The  larger  smooth  elastic  tumor  is  obviously  a  cyst. 
The  smaller  nodules  likewise  are  cysts.  The  absence  of  interstitial 
thickening  makes  the  presence  of  malignant  areas  unlikely. 

Treatment. — The  cyst-bearing  area  was  resected. 

PatJiology. — The  larger  and  smaller  tumors  are  cysts  filled  with  a 
clear  fluid.      There   is   a   little   thickening   of   the   interstitial   tissue 


DISEASES    OF    THE   BREAST 


361 


lateral  to  the  outermost  cyst  (Fig.  180).  This  is  elastic,  miiformly 
pink  with  a  few  areas  of  very  small  white  dots.  These  on  section 
are  seen  to  be  little  changed  gland  acini  (Fig.  181). 

After-course. — The  patient  is  free  after  ten  years.     The  opposite 


> .  '•  ■  j«^'*^.-IJ.  7^ 


•;:^'i 

f 


Fig.    181. — Normal   gland   acini    near   a    cyst. 

breast,  which  at  the  time  of  operation  showed  many  fine  cj^sts,  has 
atrophied  into  a  flat,  smooth  breast. 

Comment. — A  cyst-bearing  area,  when  well  defined,  is  subject  to 
ready  resection.  A  cystic  breast  without  interstitial  thickening  may 
be  with  safety  allowed  to  go  untreated. 

CASE  3. — A  matron  of  forty-two  came  to  me  because  of  a  tumor 
in  her  breast. 

History. — For  several  months  the  patient  has  noticed  a  lump  in 
her  left  breast.  There  is  sometimes  a  stinging  sensation  but  no  real 
pain.  She  has  three  children  whom  she  nursed  without  incident. 
There  are  no  pelvic  symptoms. 


362  CLINICAL   SURGERY   BY    CASE    HISTORIES 

Examination. — The  breasts  are  both  large  and  firm.  Lateral  and 
above  the  left  nipple  is  a  giobnlar  mass  the  size  of  a  walnut,  Avhich 
is  quite  firm.  It  seems  smooth,  yet  does  not  move  freely  about  the 
tissue.  There  is  no  retraction  of  the  nipple  or  skin  or  limitation  of 
movements  in  the  change  of  position. 

Diagnosis. — The  firmness  and  roundness  suggest  a  cyst.  The  fixa- 
tion differentiates  it  from  a  fibroadenoma.  The  age  of  the  patient  like- 
wise favors  a  cyst.  The  stinging  sensation  makes  one  apprehensive 
of   malignancy,    but    there   are   no    physical    signs    indicative    of    it. 


v'fi 


c^^^cT'  <.''^<:^:'-  O^jS^ 


,'/v 


£f^  V 


Fig.  182. — A.  Cyst  with  smooth  walls.  Small  dots  in  the  connective  tissue  suggesting 
cancer  nests.  B.  This  slide  shows  the  dots  to  be  composed  of  acini  well  within  the  base- 
ment membrane. 

Xevertheless,  exploratory  operation  must  be  undertaken  with  grave 
apprehension. 

Treatment. — The  patient  Avas  told  the  trouble  probably  was  benign, 
but  that,  should  the  lesion  prove  otherwise,  the  radical  operation 
should  follow  at  once.  A  wedge-shaped  piece  of  the  breast  including 
the  tumor  was  removed. 

PatJwlogy. — A  cyst  the  size  of  a  walnut  made  up  the  tumor  (Fig. 
182-A).  The  portion  of  the  breast  removed  along  with  it  Avas  elastic, 
pink  for  the  most  part,  with  fine  points  intermingled.  These  fine 
points  were  seen  to  be  groups  of  gland  acini.     The  cells  of  these  acini 


DISEASES    OF    THE   BREAST  363 

are  deeply  staining  and  the  basement  membranes  are  intact  and  there 
is  no  round-celled  infiltration  (Fig.  182-B). 

After-course. — The  patient  had  an  annoying  hemorrhage,  a  hema- 
toma formed  and  continued  to  drain  for  a  number  of  days  following 
the  operation.  The  hemorrhage  was  controlled  with  difficulty  with 
pad  compresses  and  adhesive  strips. 

Comment. — The  fact  that  this  woman  is  of  the  buxom  type  with 
large  breasts  makes  conservative  operating  particularly  disquieting. 
Coupled  with  this  was  the  complaint  of  stinging  pain,  usually  in- 
dicative of  early  malignancy.  Adding  to  the  apprehension  was  the 
annoying  hemorrhage,  a  thing  calculated  to  stimulate  to  malignancy 
if  there  is  a  tendency  thereto.  In  resecting  breasts,  particularly  if 
done  under  epinephrin-adrenalin,  every  precaution  possible  should 
be  undertaken  to  prevent  hemorrhage  into  the  space  left  by  the  por- 
tion of  breast  removed.  This  can  best  be  done  by  transplanting  a 
flap  of  fat  from  the  neighboring  subcutaneous  tissue  or  by  pulling  the 
remainder  of  the  breast  together  by  catgut  sutures.  If  the  job  does 
not  result  satisfactorily,  a  small  drain  for  a  day  or  two  will  do  no 
harm.  A  hematoma  is  a  very  annoying  thing,  for  it  must  either 
be  removed  or  absorption  awaited,  which  may  require  several  months. 
This  gives  time  for  the  asking  of  many  questions  which  may  even  be 
directed  to  the  surgeon  who  counseled  radical  operation. 

CASE  4. — An  unmarried  woman  of  thirty-eight  came  to  the  hos- 
pital because  of  a  tumor  of  the  breast. 

History. — She  was  struck  in  the  left  breast  a  year  ago  by  a  child. 
Two  days  later  she  noticed  blood  oozing  from  the  nipple.  This  kept 
up  at  intervals  since.  Once  there  seemed  to  be  pus  coming  from 
the  nipple.  During  many  months  there  was  no  pain.  Four  months 
ago  she  noticed  a  swelling  which  would  disappear  for  weeks  at  a  time, 
then  reappear.  It  is  now  larger  than  ever  before  and  has  become 
painful.  The  whole  breast  is  swollen  and  sore  and  there  is  more 
blood  escaping  now  than  ever.  Her  general  health  is  good.  Men- 
struation is  regular  and  but  little  painful.  The  laboratory  findings 
are  negative. 

Examination. — The  left  breast  is  larger  than  the  right  as  noted 
by  inspection.  The  nipple  is  not  displaced  or  retracted,  but  a  fine 
droplet  of  watery  blood  oozes  from  the  nipple  without  the  application 
of  pressure.     By  palpation  an  irregular  mass  is  felt  medial  to  the 


364  CLINICAL   SURGERY   BY    CASE    HISTORIES 

nipple.  It  seems  to  shade  off  gradually  into  the  surrounding  tis- 
sues. The  mass  is  made  up  of  irregular  nodules  with  smooth  surfaces. 
The  whole  mass  gives  one  the  sensation  of  tense  elasticity.  The  nip- 
ple is  not  retracted  and  traction  on  it  does  not  change  the  position 
of  the  mass.  The  axilla  is  free.  The  opposite  breast  is  thickened 
and  hard  and  many  small  smooth  nodules  can  be  felt. 

Diagnosis. — The  spontaneous  escape  of  blood  from  the  nipple  signi- 
fied a  cyst  of  the  breast  containing  a  papillary  outgrowth.  It  is  the 
papilla  that  furnishes  the  blood.  The  injury  from  the  child's  head 
evidently  was  sufficient  to  cause  bleeding  in  a  papillary  growth  al- 
ready present.  The  rather  sudden  appearance  of  a  tumor  mass  with 
a  general  enlargement  of  the  breast  with  pronounced  pain  may  be 
ascribed  to  hemorrhage  into  the  cyst  with  associated  reaction  of  the 
surrounding  tissue.  If  the  increase  in  size  were  due  to  malignant 
degeneration,  the  growth  would  have  been  less  rapid,  the  pain  not 
so  great,  sticking  rather  than  bursting  in  character,  and  the  con- 
sistency would  have  been  hard  rather  than  tense  elastic.  Some  sur- 
geons regard  the  appearance  of  blood  in  the  nipple  as  pathogno- 
monic of  malignancy,  but  this  view  has  been  abundantly  disproved. 

Treatment. — The  affected  area  was  rather  widely  excised  taking 
in  the  major  portion,  but  not  all  of  the  thickened  tissue.  Some  por- 
tions of  interstitial  mastitis  were  allowed  to  remain.  Since  the  other 
breast  was  similarly  affected,  this  was  not  regarded  as  of  moment. 

PatJioIogy. — On  ^ross  examination  the  cut  surface  shows  a  general 
pale  pink  background  intermingled  with  many  small  cysts.  These 
cysts  are  in  part  empty  and  in  part  filled  with  deep  red  tissue  or 
blood  clot  (Fig.  183).  There  is  some  infiltration  of  the  surrounding 
tissue  about  one  of  the  cysts.  The  intercystic  tissue  is  everywhere 
elastic.  The  section  shows  that  some  of  the  cysts  are  partly  filled 
by  a  proliferation  of  cells  (Fig.  183)  and  in  part  by  papillary  out- 
growths (Fig.  184).  In  none  of  these  is  there  any  escape  through 
the  basement  membrane,  though  in  some  places  there  is  a  round-celled 
infiltration.  This  is  particularlj'  true  in  the  region  where  hemorrhage 
has  taken  place  into  the  surrounding  tissues. 

After-course. — Healing  was  uninterrupted  and  no  recurrence  has 
appeared. 

Comment. — The  central  factor  in  this  case  is  that  of  justification  of 
conservative  treatment.  It  is  not  malignant — now.  The  areas  in  which 
the  chief  disturbing  processes  were  going  on  have  been  removed.    The 


DISEASES   OF    THE   BREAST 


365 


Fig.    183. — Mammary   cyst  partly   filled  with   cells. 


Fig.    184. — Mammary   cyst   with   papillary   projections   into    the   cyst   cavity. 


366  CLINICAL   SURGERY   BY    CASE    HISTORIES 

portion  of  breast  reniaiiiing-  presents  no  clianges  other  than  those 
found  in  the  otlier  breast.  There  is  as  much  excuse  for  removing  the 
other  breast  as  for  removing  the  remainder  of  the  breast  operated. 
The  conservative  operation  made  the  restoration  of  the  breast  contour 
possible,  making  tlie  esthetic  loss  nil.  The  patient  believed  that 
the  loss  of  the  whole  breast  would  destroy  her  chances  for  marriage 
and  the  bearing  of  children.  She  is  willing  to  assume  the  risk  of 
malignancy  rather  than  this  loss.  Those  who  have  children  will  not 
fail  to  regard  her  viewpoint  with  symjDathy.  She  has  had  the  benefit 
of  a  careful  clinical  and  microscopic  examination  to  safeguard  her 
and  the  surgeon  is  not  justified  in  refusing  to  assume  the  modicum 
of  responsibility  that   necessarily   accrues  to  him   in   such   instance:-!. 

CASE  5. — A  housewife  aged  thirty-nine  came  to  the  hospital  be- 
cause of  a  tumor  of  her  breast. 

Hist  or  ij. — The  patient  has  one  child  eleven  years  old,  but  has  had 
no  miscarriages.  Her  menses  are  regular,  lasting  two  or  three  days 
and  are  always  painful.  She  has  had  a  dragging  pain  in  the  pelvis  for 
six  years.  It  is  worse  when  she  is  much  on  her  feet.  She  has  been 
tamponed  at  various  times  and  experienced  some  relief  from  the 
treatment.  Six  months  ago  she  noticed  some  lumps  in  the  left  breast. 
She  does  not  think  they  have  grown  since  she  discovered  them.  S'le 
has  occasional  twinges  in  the  breast,  but  no  actual  pain.  These 
twinges  are  not  confined  to  the  menstrual  period.  She  is  not  con- 
scious of  any  unusual  sensations  in  the  breast  at  the  menstrual  period 
either  at  the  present,  since  the  tumors  have  appeared,  or  at  any  time 
in  the  past.  She  had  inflammation  in  both  breasts  at  the  time  she 
was  nursing  the  baby,  but  neither  came  to  abscess. 

Examination.- — There  is  a  medium  laceration  of  the  perineum  and 
cervix.  The  breast  is  made  up  of  a  conglomeration  of  c.ysts.  They 
are  round,  tense,  and  seem  to  be  circumscribed.  There  are  several 
as  large  as  a  walnut  and  many  smaller  ones.  These  tumors  are 
spherical  and  seem  well  circumscribed.  The  nipple  and  skin  are  un- 
attached and  the  whole  breast  glides  freely  over  the  underlying  fas- 
cia. The  larger  one  is  definitely  tense  elastic  and  seems  attached 
to  the  breast  tissue  at  one  point. 

Diagnosis. — The  multiplicity  of  the  nodules  in  the  breast  stamps 
it  as  a  cystic  condition.     They  are  less  freely  movable,  lack  bosse- 


DISEASES    OF    THE    BREAST 


367 


lations,  and  are  more  numerous  than  one  would  find  in  fibroadenomas 
or  mixed  tumors.  The  only  problem  is  whether  or  not  a  malignant 
condition  has  been  engrafted  on  the  cystic  condition.  The  occasional 
twinges  of  pain  she  speaks  of  strongly  suggest  the  possibility  of  a 
beginning  malignancy.  The  breast,  like  its  fellow,  is  made  up  of 
a  pad  of  fibrous  tissue  resembling  much  a  cook's  first  attempt  at  mak- 
ing a  pancake — flat  and  tense  elastic.  On  the  affected  side  the 
cysts  are  embedded  in  this.     There  is  nowhere  an  increased  density 


Fig.   185. — Interstitial  mastitis  with  C3-st  formation.     Below  the  larger  cyst  is  a  malignant  area. 

of  the  background,  though  its  existence  can  not  be  excluded.  The 
clinical  diagnosis,  therefore,  is  interstitial  mastitis  with  cyst  forma- 
tion. 

Treatment. — The  breast  was  exposed  and  excised  in  various  places. 
The  larger  cyst  contained  a  milky  fluid  (galactocele)  while  the  smallei 
ones  contained  a  clear  fluid.  The  interstitial  tissue  everywhere  was 
pale  pink  and  elastic.  Because  the  breast  was  so  evidently  cystic, 
extensive  section  was  not  done.  The  entire  breast  was  excised.  There 
was  not  enough  fat  on  the  chest  to  make  a  new  breast.  The  cervix  and 
perineum  likewise  were  repaired. 


368 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


PatJwlogy. — Tlie  iiit(>rstitial  tissue  iiowliere  showed  epithelial  iiifil- 
tration  but  many  small  cysts.  The  slide  made  by  tlie  technician 
showed  extensive  interglandular  proliferation  and  numerous  small 
cysts  without  epithelial  proliferation.  The  acini  stained  deeply  but 
showed  no  proliferation.  Tlie  aeeompanying'  photograph  of  the  gross 
specimen  (Fig.  185)  however,  showed  a  definite  area  of  malignancy 
just  below  the  larger  cyst.  A  section  from  this  area  showed  malig- 
nancy (Fig.  186). 


%'^^^:ZJ'.^- 


■■■■•>■,' 


'     T 


^* 


Fig.    186. — Beginning    carcinoma    of    the    breast.      A.  Epithelial    cell    nests.      B.  Acini    of    in- 
terstitial mastitis. 


After-course. — Healing  was  uneventful  and  recovery  has  been  p?r- 
manent. 

Comment. — AVhen  one  breast  shows  cystic  deg.nieration,  any  pelvic 
disorder  should  be  corrected,  for  by  so  doing  the  unaffected  breast 
is  less  likely  to  become  cystic.  Ordinarily,  a  c^'stic  breast  can  be 
managed  by  the  excision  of  the  breast.  In  cystic  breasts  the  occa- 
sional appearance  of  twinges  of  pain  should  cause  apprehension. 
The  development  of  cysts  alone,  however,  may  cause  unpleasant  feel- 
ings of  distension  but  usually  not  twinges  of  pain.  Such  breasts 
always  demand  careful  search  at  the  operating  table.    Had  that  been 


DISEASES    OF    THE    BREAST  369 

done  in  this  instance,  this  smaller  area  would  not  have  been  over- 
looked.    Even  careful  palpation  should  have  discovered  it. 

CASE  6. — A  housewife  of  thirty-seven  came  to  the  hospital  be- 
cause of  a  tumor  of  the  breast. 

History. — The  patient  has  had  a  tumor   of  the  breast   seventeen 
years.     It  developed  before  weaning  her  second  and  youngest  child. 


Fig.    187. — Cystic   carcinoma  with   collapsed  walls. 


70 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


She  weaned  the  baby  because  she  thought  it  was  a  "caked  breast." 
It  continued  to  be  inflamed,  however,  and  increased  in  size.  After  a 
time  the  reddening  and  pain  lessened  though  the  size  of  the  tumor 
did  not  diminish.  Seven  months  ago  it  began  to  enlarge  and  it  is 
now  as  large  as  a  list.  It  has  caused  lier  no  pain  but  the  rapid  in- 
crease in  size  alarmed  her. 

Examination. — The  left  breast  is  represented  by  a  large  globular 
mass,  dense,  elastic  to  the  touch.  Careful  palpation  shows  slight  bos- 
sellations  at  several  points  on  its  surface.     The  skin  is  adherent  over 


Fig.    U 


-Malignant    area   in    the   wall    uf    a    cystic    carcinoma. 


the  surface,  and  lateral  to  the  nii)ple  it  is  red  and  infiltrated.  It  is 
not  freely  movable  over  the  pectoral  fascia.  There  are  no  axillary 
Ij-mph  glands  palpable.  It  is  slightly  tender  on  palpation.  The  skin 
over  the  surface  is  decidedly  reddened. 

Diagnosis.- — The  history  of  beginning  at  the  end  of  lactation  with 
a  long  dormant  stage  suggests  a  chronic  abscess.  Evidently  some 
secondary  process  has  become  active,  either  renewed  inflammation  or 
a  malignancy.  The  irregular  character  of  the  surface  suggests  malig- 
nancy, but  the  suggestion  of  elasticity  hints  of  a  cavity  with  a 
tliick  wall.     Were  it  not  for  the  historv  one  would  think  of  colloid 


DISEASES    OF    THE    BREAST  371 

carcinoma  approaching  the  skin  as  is  manifest  by  the  reddening.  The 
history  of  recent  rapid  development  with  the  small  nodnles  on  the  sur- 
face were  deemed  to  dominate  the  picture  and  malignancy  was  diag- 
nosed. 

Treatment. — The  radical  operation  was  done.  It  was  necessary  to 
excise  a  wide  area  of  skin.  The  deficit  was  replaced  at  once  by  skin 
grafts  from  the  thigh. 

Pathology. — On  section  the  tumor  mass  was  found  to  contain  a 
cavity  filled  with  a  granular  milky  fluid  and  some  colloid  material. 
With  the  escape  of  the  fluid  the  walls  collapsed  (Fig.  187).  The 
wall  was  covered  with  an  irregular  colloid  mass.  Surrounding  this, 
particularly  on  the  lateral  border,  was  a  mass  of  colloidal  tumor  tis- 
sue showing  definite  evidence  of  malignancy  (Fig.  188).  The  skin 
overlying  this  area  was  reddened. 

After-course. — The  operation  wound  healed  promptly,  but  the 
patient  died  a  year  and  a  half  afterwards  from  general  systemic 
metastasis. 

Comment. — Generally  speaking  this  tj'pe  of  tumor  gives  a  fairly 
good  prognosis,  and  when  they  do  return,  the  recurrence  is  apt  to 
be  local.     The  systemic  metastasis  came  as  a  surprise. 


CHAPTER  IX 
DISEASES  OF  THE  UPPER  EXTREMITY 

Affections  of  the  upper  extremity  have  to  do  witli  diseases  danger- 
ous to  life,  painful  affections  and  affections  which  tend  to  limit  move- 
ment. The  first  group  comprises  neoplastic  diseases  and  some  infec- 
tions; the  second  neuralgias  and  some  infections,  and  the  last  the 
result  of  some  disease  or  trauma. 

DISEASES  OF  THE  SHOULDER  REGION 

Aside  from  frank  traumas,  such  as  fracture  and  dislocation,  the 
chief  diseases  are  arthritides  and  affections  of  the  bursie  and  neural- 
gias. The  former  most  often  is  characterized  by  limitation  of  motion 
with  pain,  the  latter  by  pain  with  limitation  of  motion  by  muscle 
spasm  only. 

CASE  1. — A  matron  of  forty-eight  came  to  the  hospital  because 
of  a  painful  shoulder. 

History. — Since  last  April  there  has  been  a  gradually  developing 
pain  when  she  attempted  to  raise  her  left  arm.  This  was  particularly 
noticeable  when  she  attempted  to  comb  her  hair.  There  was  a  dull 
pain  and  aching  in  the  left  shoulder  most  of  the  time  but  it  was  much 
increased  on  trying  to  raise  her  arm.  Her  general  health  is  pretty 
good  most  of  the  time.  She  had  one  attack  of  pain  in  the  left  hip 
twelve  years  ago  which  lasted  eleven  weeks.  It  was  called  sciatica. 
A  lipoma  was  removed  from  her  left  shoulder  fifteen  years  ago. 

Examination. — There  is  a  spot  tender  to  pressure  near  the  end  of 
acromion  process.  The  x-ray  shows  a  shadow^  external  to  acromion 
and  about  the  head  of  the  humerus  and  independent  of  both  (Fig. 
189).  Pressure  over  this  point  with  passive  motion  causes  an  increase 
of  pain.    Pain  is  made  worse  by  active  motion  made  against  resistance. 

Diagnosis. — The  history  is  that  of  a  bursitis.  The  x-ray  suggests 
that  bony  changes  have  taken  place  in  it.  The  disability  is  great 
enough  to  induce  the  patient  to  accept  anj"  means  that  offers  relief. 


DISEASES    OF    THE    UPPER    EXTREMITY 


373 


Treatment. — The  bursa  was  exposed,  the  wall  found  thickened  but 
no  bony  changes.    It  was  removed. 

Pathology. — The  capsule  was  thick  and  showed  hyaline  changes. 

After-course. — The  patient  was  completely  relieved  and  full  motion 
restored. 

Comment. — The  only  certain  treatment  for  bursitis  is  removal.  It 
is  more  expeditious  and  more  certain  and  less  dangerous  than  injec- 
tion. In  recent  mild  cases  immobilization  with  compression  may  give 
relief. 


Fig.   189.— Bursitis  v/ith  apparent  bony  formation  or   calcareous   deposit. 


374  CLINICAL   SURGERY   BY    CASE    HISTORIES 

CASE  2. — A  schoolboy  aged  nineteen  came  because  of  pain  and 
stiffness  in  his  shoulder. 

Ilistor)/. — The  patient  has  had  a  painful  shoulder  for  a  year  and 
a  half.  It  has  never  been  swollen  to  speak  of  but  all  movements  are 
painful.  No  other  joints  have  been  affected.  He  has  had  no  venereal 
disease  and  no  history  of  infection  or  trauma. 

Examination. — The  arm  muscles  were  atrophied  and  the  deltoid 
was  flat.  The  shoukler  joint  was  not  thickened  and  not  tender  upon 
gentle  examination.     When  passive  movement  was  attempted  loud 


Fig.    190. — Dry    tubercul.  -:  -       i      !;-     shoulder. 

protestations  were  offered.  The  littk^  movements  that  were  permitted 
gave  rise  to  a  grating  sensation.    All  other  joints  were  free. 

Diagnosis. — Being  monoarticular,  arthritis  deformans  was  unlikely. 
He  seemed  to  be  telling  the  truth  when  he  denied  venereal  infection. 
There  was  no  evidence  of  septic  infection  and  since  the  onset  was 
gradual  this  may  he  excluded.  It  had  the  roughened  feel  of  a  bone 
tuberculosis,  hence  a  dry  tuberculosis  may  be  diagnosticated.  The 
patient  was  observed  before  the  days  of  the  general  use  of  the  x-ray. 

Treatment. — On  the  advice  of  an  older  colleague  the  shoulder  was 
resected  through  the  surgical  neck. 

Pathology. — The  point  of  attachment  of  the  muscles  about  the 
great  tuberosity  was  partly  undermined  b}'  granulation  tissue.     The 


DISEASES    OF    THE    UPPER   EXTREMITY  375 

whole  head  was  denuded  of  cartilage  and  about  the  anatomic  neck 
patches  of  granulation  tissue  elevated  the  periosteum  (Fig.  190). 
This  granulation  tissue  was  not  distinctive  of  tuberculosis  but  an 
emulsion  of  it  injected  into  a  guinea  pig  brought  a  positive  result 
in  five  weeks. 

Aftercourse. — The  wound  healed  with  good  passive  and  fair  ac- 
tive motion.     The  patient  was  lost  sight  of. 

Comment. — I  believe  resection  should  not  have  been  done  in  this 
case.  I  have  seen  good  residts  in  young  persons  by  conservative 
treatment  in  equally  unpromising  conditions.  Should  I  meet  the 
same  condition  in  a  patient  in  middle  life,  however,  I  should  resect, 
for  experience  has  taught  that  but  little  can  be  expected  in  the 
healing  of  tuberculosis  of  the  joint  after  the  epiphyseal  line  has 
become  obliterated.  I  regard  a  correct  diagnosis  in  this  case  as  a 
mistake  in  clinical  logic,  a  happy  guess.  It  was  observed  long  be- 
fore general  knowledge  of  septic  joint  infections  was  as  dissemi- 
nated as  it  is  today.  Should  I  see  a  like  condition  today,  I  should  not 
have  the  courage  to  make  such  a  diagnosis,  and  had  not  tubercle 
bacilli  been  stained  in  the  tubercles  of  the  guinea  pig  I  should  be 
.skeptical.  It  is  well  to  know  that  such  lesions  do  occur.  I  saw  a  sim- 
ilar case  in  the  practice  of  J.  N.  Jackson  a  few  years  previously. 

CASE  3. — A  child  aged  six  was  brought  to  the  hospital  because 
of  a  swollen  arm. 

History. — Ten  days  ago  after  a  period  of  vigorous  play  in  the  yard 
on  Christmas  day  she  became  feverish  and  complained  of  general 
pains.  There  was  no  tonsillitis  and  no  known  injury.  A  week  ago  she 
began  to  complain  of  pain  in  the  arm  between  the  shoulder  and  elbow 
and  two  days  later  swelling  in  this  region  appeared.  She  has  been 
feverish  and  listless. 

Examination. — The  arm  is  swollen,  very  sensitive,  but  despite  this 
one  perceives  fluctuation.  The  shoulder  and  elbow  joints  are  painful 
on  manipulation.    The  pulse  is  140,  the  temperature  103.6. 

Diagnosis. — The  physical  findings  leave  no  doubt  as  to  the  diag- 
nosis, acute  suppurative  osteomyelitis. 

Treatment. — Free  incision  in  the  soft  parts  and  a  wide  opening 
into  the  medulla  was  made.  There  was  much  pus  about  and  within 
the  bone.    The  wound  was  loosely  packed. 

After-course. — There  was  some  improvement  in  the  general  symp- 


376  CLINICAL    SURGERY    BY    CASE    HISTORIES 

toms  for  a  day,  but  after  that  the  general  hebitnde  returned  and 
gradually  increased  and  she  died  on  the  sixth  day. 

Comment. — Early  incision  would  have  greatly  enhanced  the  chances 
of  saving  this  child's  life.  Pain  and  tenderness  of  a  long  bone  at- 
tended by  fever  in  a  child  is  sufficient  cause  for  action. 

CASE  4. — A  farmer  aged  forty  came  to  the  hospital  because  of 
a  painful  swelling  under  his  arm. 

History. — The  patient's  trouble  began  ten  days  before  with  chills 
and  fever  which  rose  to  103.6°.  The  chills  and  fever  recurred  on  the 
third  and  fifth  days.  His  physician  diagnosticated  malaria  and  gave 
quinine.  Since  then  he  has  had  no  chills  and  the  temperature  has  re- 
mained lower,  but  more  persistent,  liowever,  so  that  now  it  varies  be- 
tween 101°  and  102.5°.  At  this  time  he  had  a  deep  pain  in  the  left 
chest  and  shoulder  and  marked  tenderness  in  the  axilla.  He  is  much 
prostrated,  has  no  appetite  and  complains  of  constant  pain  in  front  of 
the  left  shoulder  and  axilla,  chiefly,  but  the  whole  side  is  sore. 

Examination. — The  patient  is  a  huge  man  bearing  evidence  of  the 
use  of  alcoholics,  though  not  now  under  its  influence.  The  left  hu- 
merus is  held  slightly  abducted  from  the  chest  and  the  forearm  is 
supported  by  the  right  hand.  He  asks  caution  when  the  left  arm  is 
grasped  by  the  examiner.  The  axilla  is  swollen.  The  posterior 
border  of  the  axilla  is  less  markedly  protuberant.  On  palpation  he 
protests  vigorously.  The  area  above  indicated  is  enlarged,  no  definite 
tumor  mass  can  be  made  out  and  no  fluctuation,  merely  an  enlarge- 
ment that  is  exquisitely  tender.  On  query  he  exhibits  a  small  ab- 
rasion of  the  index  finger  now  nearly  healed  which  he  states  he 
received  by  striking  against  the  side  of  a  box  ten  days  ago.  It  did 
not  give  him  any  trouble  then  or  since,  he  is  sure. 

Diagnosis. — The  onset  with  chill,  and  intermittent  fever  simulat- 
ing remittent  fever,  is  not  uncommon  in  generalized  infections  and 
until  there  was  evidence  of  a  localized  process,  its  nature  might  easily 
have  been  overlooked.  The  lack  of  fluctuation,  or  of  a  palpable  mass 
or  glands  in  the  jiresence  of  unmistakable  evidence  of  axillary  sup- 
puration indicates  an  abscess  of  the  axilla  below  the  deep  axillary 
fascia.  This  fascia  prevents  the  appearance  of  a  definite  tumor  as 
well  as  of  fluctuation.  The  old  injury  is  in  line  with  the  chief  trouble 
and  may  safely  be  indicted  as  the  offending  factor. 

Treatment. — A  free  incision  was  made  along  the  outer  border  of  the 


DISEASES    OF    THE    UPPER    EXTREMITY  377 

pectoralis  major  tendon  and  the  deep  fascia  incised.  A  large  amount 
of  a  semitransparent  colorless  pus  escaped  with  some  force.  The  finger 
entered  a  cavity  as  large  as  a  goose  egg  extending  well  up  into  the  ax- 
illary triangle  under  the  clavicle  to  above  the  first  rib.  A  large 
rubber  tube  was  introduced. 

Pathology. — This  pus  showed  staphylococci  and  short  rods  not  more 
closely  identified. 

Comment. — Several  months  elapsed  before  the  large  cavity  was 
finally  obliterated.  These  cases  before  they  localize  are  very  discon- 
certing. The  leucocytosis  often  is  high  and  then  some  sort  of  infec- 
tive process  may  be  suspected,  a  suspicion  heightened  by  the  absence 
of  any  evidence  of  malaria.  The  presence  of  the  small  abrasion  on 
the  finger  should  have  cleared  up  the  diagnosis  on  the  very  first 
evidence  of  axillary  infection.  Early  incision  with  free  drainage 
is  desirable. 

CASE  5. — A  clergyman  aged  thirty-six  came  to  me  because  of  a 
painful  lump  in  the  axilla. 

History. — For  three  months  he  has  been  aware  of  a  painful  swell- 
ing in  the  axilla.  He  knows  no  cause  for  its  appearance.  He  has  had 
no  other  enlarged  glands  and  he  knows  of  no  family  tuberculosis. 
During  the  past  month  it  has  been  so  painful  as  to  greatly  discommode 
him. 

Examination. — A  mass  the  size  of  an  apple  occupies  the  axillary 
space  causing  a  marked  bulging.  It  is  hard,  tender  to  the  touch,  and 
firmly  fixed.  There  are  no  supraclavicular  glands  palpable.  The 
hand  gives  no  evidence  of  a  past  infection.  Laboratory  examinations 
are  all  negative. 

Diagnosis. — Because  of  the  indolent  character  of  the  growth  pus 
microbe  infection  is  unlikely.  An  isolated  mass  is  unusual  in  syph- 
ilis. The  conglomerate  adhesion  of  the  various  parts  speaks  for 
tuberculosis,  as  against  Hodgkin's  disease.  On  the  other  hand,  the 
development  is  rapid  for  tuberculosis  and  the  degree  of  pain  unusual 
so  that  a  mixed  infection  is  not  beyond  the  possibility. 

Treatment. — The  entire  axillary  contents  were  blocked  out. 

Pathology. — "When  the  mass  is  cut  through,  numerous  glands  are 
seen  to  be  embedded  in  masses  of  indurated  periglandular  material 
(Fig.  191).  Whitish  gray  well-circumscribed  points  are  readily  made 
out  in  some  of  the  glands.     The  larger  one  of  the  glands  is  lique- 


378 


CLINICAL   SURGERV    BY    CASE    HISTORIES 


fying  but  shows  a  few  of  the  areas  above  mentioned.  The  slides 
show  typical  tubercles. 

After-course. — The  wound  healed  readily.  He  has  remained  free 
from  any  further  glandular  infection. 

Comment. — AYhenever  an  isolated  tuberculous  lesion  can  be  clearly 
dissected  out,  this  presents  the  ideal  method  of  treatment.  The  more 
acute  the  process  is  in  its  origin  and  the  greater  the  periglandular 


Fig.   191. — Infected  lymphatic  glands  of  the  axiUa. 

infection,  the  better  the  prospect  that  the  local  excision  will  secure 
results.  In  the  acute  infections  all  the  glands  involved  give  evi- 
dence of  the  infection.  In  the  chronic  infections  glands  but  slightly 
involved  may  escape  the  examiner's  touch,  but  after  the  lesions  have 
been  removed  they  develop,  not  because  of  the  operation  but  to  this 
preexisting  condition.  Again  the  lesions  are  central,  well  walled  in  hj 
reaction  on  the  part  of  the  periglandular  tissue,  and  miliary  dis- 
semination is  less  likely  to  take  place  than  in  the  more  chronic  proc- 
esses. The  acute  processes,  too,  are  more  apt  to  occur  in  robust  in- 
dividuals. 

CASE  6. — A  man  aged  forty  went  to  Bell  Hospital  because  of  a 
swelling-  on  his  back. 

History. — The  patient's  general  health  has  always  been  fair.     He 
has  had  some  pain  in  the  left  side  for  a  year  or  more.     During  the 


DISEASES    OF    THE    UPPER    EXTREMITY 


379 


past  six  months  he  has  noticed  a  swelling  in  the  back  which  has  gracl- 
uallr  increased  to  its  present  size. 

Examination. — An  obliqne,  slightly  lobnlated  tumor  extends  from 
the  angle  of  the  scapula  to  the  lower  border  of  the  twelfth  rib  (Fig. 


Fig.  192. — Abscess  following  tuberculosi 


380  CLINICAL    SURGERY   BY    CASE    HISTORIES 

192).  It  changes  its  position  slightly  as  the  position  of  the  patient 
changes.  On  palpation  it  is  found  to  be  distinctly  fluctuating  as 
though  a  thin  fluid  were  confined  immediately  beneath  the  skin. 

Diagnosis. — From  inspection  I  at  once  suspected  a  lipoma.  Pal- 
pation, however,  showed  that  it  must  be  a  sac  containing  a  thin 
fluid.  A  quantity  of  fluid  so  great  in  this  situation  is  very  un- 
usual. The  history  of  pain  in  the  side  for  a  year  or  more  sug- 
gested a  burrowing  empyema,  but  the  thoracic  cavity  was  free 
from  fluid  and  burrowing  empyema  would  have  perforated  the 
skin  before  attaining  this  size.  A  subscapular  bursitis  is  more  tense, 
and  none  so  large  has  been  recorded.  This  seemed  to  me  to  be  the 
probable  diagnosis,  however.  A  cold  abscess  from  a  tuberculous  rib 
tends  to   follow  the   intercostal   spaces  toward  the   front. 

Treatmoit. — The  late  Dr.  Walter  Sutton  operated  on  the  patient 
and  discovered  a  tuberculous  rib,  which  he  resected. 

After-course. — The  patient's  after-history  is  not  known. 

Comment. — Eib  tuberculosis  may  occur  independently  of  any 
other  tuberculous  lesion  or  from  extension  of  a  pleural  affection.  I 
'have  never  seen  any  other  in  which  the  exudate  was  so  large  or  one 
which  failed  to  follow  the  rib  in  front.  It  is  my  opinion  that  the 
subscapular  bursa  became  involved,  and  that  it  was  in  fact  the  sac 
that  attained  this  huge  size. 

CASE  7. — A  housewife  of  fifty  came  to  the  hospital  because  of  a 
tumor  on  her  shoulder. 

History. — For  several  years  the  patient  has  had  a  tumor  on  her  back. 
It  has  caused  no  inconvenience  save  for  its  size. 

Examination. — The  region  of  the  lower  angle  of  the  scapula  is  oc- 
cupied by  a  soft  semifluctuating  tumor  (Fig.  193).  It  slides  readily 
over  the  underlying  structures  and  is  not  attached  to  the  skin.  The 
border  is  serrated. 

Diagnosis. — The  soft  semifluctuating  character  of  the  tumor  to- 
gether with  the  irregular  lobulations  makes  the  diagnosis  of  lipoma 
plain. 

Treatment. — Removal  under  local  anesthesia. 

After-course. — Relief,  of  course,  was  permanent. 

Comment. — The  site  is  typical  for  lipoma  and  the  diagnosis  is  easy. 
Occasionally  other  conditions  are  found  that  bear  a  certain  resem- 
blance. 


DISEASES   OF    THE   UPPER   EXTREMITY 


381 


Fig.   193. — Lipoma  of  shoulder. 

CASE  8. — A  school  girl  of  thirteen  was  brought  to  the  hospital 
because  of  imperfect  motion  of  the  arm  following  a  fall  on  the 
shoulder. 

History. — Six  weeks  ago  the  patient  fell  from  a  horse,  striking  on 
the  right  shoulder.  The  shoulder  began  to  pain  immediately  and  she 
could  not  move  the  arm.  A  local  doctor  said  the  shoulder  was  sprained, 
and  he  put  the  arm  in  a  sling.  A  few  days  after  the  injury  the 
skin  along  the  inner  side  of  the  arm  became  discolored.  A  week  and 
a  half  after  the  injury  an  osteopath  pronounced  the  shoulder  dislo- 
cated and  set  (?)  it  under  ether.  After  this  maneuver  there  was  no 
change  in  the  range  in  mobility  and  the  pain  was  much  increased. 

Examination. — The  patient  carries  her  arm  in  a  sling  and  expresses 
apprehension  when  examination  is  attempted.  The  skin  near  the 
shoulder  shows  faint  traces  of  yellowish-green  discoloration.  The 
arm  is  thinner  than  its  fellow.  The  axis  of  the  humerus  points  more 
medialh"  than  that  of  the  opposite  side.  There  is  a  flattening  but 
not  a  hollowness  below  the  olecranon.  All  movements  of  the  arm  are 
limited,  whether  by  muscular  action  or  bony  limitations  it  is  not  pos- 


382 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


Fig.    194-A. — Fracture   of   neck    of   humerus. 


DISEASES    OF    THE    UPPER    EXTREMITY 


383 


^ 


Fig.    194-B. — Fracture  of   neck  of  humerus.      Replaced   and  nailed. 


384  CLINICAL   SURGERi'    BY    CASE    HISTORIES 

sible  to  determine  and  at  the  same  time  maintain  the  good  will  of 
the  patient.  Slight  abduction  and  limited  rotation  only  is  possible. 
The  x-raj  shows  a  fracture  about  the  epiphyseal  line  with  an  over- 
riding of  the  fragments  and  an  inch  of  shortening  of  the  humerus 
(Fig.  194-A). 

Diagnosis. — The  position  of  the  fragments  as  demonstrated  by  the 
x-ray  indicates  that  the  limitation  of  movement  is  largely  muscular. 
Consequently  with  full  recovery  from  the  reaction  incident  to  the 
injur}'  and  from  the  manipulations  of  the  osteopath  a  much  increased 
range  of  movement  may  be  anticipated.  However,  the  position  of 
the  lower  fragment  is  such  that  the  complete  restitution  of  function, 
particularly  that  of  bringing  the  arm  forward,  is  not  to  be  antici- 
pated. 

Treatment. — Fracture  cut  down  on,  fragments  separated,  and  ends 
approximated.  Lower  fragment  was  nailed  to  head  with  an  8  penny 
finish,  nail,  the  head  of  the  nail  having  been  left  just  under  the  skin, 
where  it  will  be  accessible  for  removal  later  (Fig.  194-B).  The  wound 
was  closed  with  a  gauze  strip  running  down  to  the  nail  head.  A 
moulded  plaster  of  paris  shoulder  cap  was  put  on  running  around 
the  ell)ow.    A  pad  was  placed  in  the  axilla. 

After-course.- — The  nail  was  removed  in  a  month.  After  three 
months  the  function  was  fully  restored. 

Comment. — "With  this  degree  of  displacement,  function  would  not 
have  been  restored  without  operation.  When  in  such  cases  the  opera- 
tor has  difficult}'  in  holding  the  fragments  after  the  drill  is  removed 
and  the  nail  is  being  placed,  the  technic  is  expedited  by  leaving  the 
drill  in  place  in  lieu  of  a  nail.  The  bone  here  is  fragile  and  care  must 
be  exercised  lest  displacement  recur  in  spite  of  the  nail.  Nothing 
short  of  a  well-fitting  plaster  cast  will  secure  this  result. 

CASE  9. — I  v^as  called  to  see  a  woman  ag-ed  sixty-eight  because 
of  swelling'  of  her  right  arm. 

History. — This  patient  was  operated  on  three  years  ago  for  carci- 
noma of  the  breast.  For  two  years  she  was  quite  free  from  disturb- 
ance. Nearly  a  year  ago  she  noticed  that  her  arm  had  begun  to 
swell.  Later  on  it  became  painful.  The  condition  has  gradually 
grown  worse  up  to  the  present  time. 

Examination. — Though  feeble  the  patient  does  not  show  cachexia. 
Her  right  arm  is  enlarged  to  half  a  dozen  times  the  size  of  its  fellow 


DISEASES   OF    THE   UPPER   EXTREMITY 


385 


(Fig.  195).  The  swelling  is  hard,  but  pits  slightly  on  pressure; 
firm  pressure  causes  pain.  A  large  scar  occupies  the  location  of  the 
breast  and  a  marked  puckering  fills  the  axilla.  Because  of  this  the 
arm  can  not  be  elevated  and  the  attempt  to  do  so  causes  pain.  There 
are  numerous  small,  hard  glands  in  the  suiDraclavicular  fossa.  No 
tumor  can  be  felt  in  the  axilla. 


Fig.   195. — Edema  of  the  arm  from  recurrent  carcinoma  of  the  breast. 


Diagnosis. — The  swelling  obviously  is  due  to  a  compression  of  the 
axillary  vein.  The  density  of  the  scar  and  its  retraction  makes  a 
local  recurrence  of  the  tumor  likel}'.  Because  of  the  denseness  of  the 
arm  the  compression  of  the  Ij'mphatics  likewise  may  be  assumed. 

Treatment. — Anodyne  for  pain  was  advised. 

Comment. — Some  surgeons  recommend  interscapulothoracic  amputa- 
tion for  this  condition.    I  do  not  believe  it  is  warranted. 


386 


CLINICAL   SrRGKRV   BY    CASE    HISTORIES 


Case  10. — A  widow  aged  fifty-eight  came  to  the  hospital  because 
of  pain  in  her  elbow. 

History. — For  several  months  she  liad  had  pain  in  her  left  elbow. 
It  is  not  constant  bnt  seems  worse  at  night.    Recently  there  has  been 

some  stiffness  in  tlio  joint.    No  other  joints  have  been  affected.     Her 


Fig.    196. — Metastatic  carcinoma   of  the   humerus. 


DISEASES    OF    THE    TPPER    EXTRE:MTTY  387 

general  health  has  been  good  save  that  she  has  had  much  backache 
lately. 

Examination. — In  small  range  the  joint  surface  seems  free.  The 
limitation  of  motion  seems  due  to  muscle  spasm.  The  bony  land- 
marks are  well  defined  and  there  is  no  exudate  into  the  joint.  The 
bone  above  the  joint  is  sensitive  to  pressure.  She  has  a  scar  in  her 
right  breast  which  she  admits  came  from  a  removal  of  a  breast  eight 
years  ago.  The  x-ray  (Fig.  196)  shows  an  extensive  area  of  involve- 
ment of  the  shaft  of  the  humerus. 

Diagnosis. — Obviously  the  pain  is  due  to  a  carcinoma,  a  metasta- 
sis from  the  breast  carcinoma.  The  pain  in  the  back  suggests  a  pos- 
sible spinal  metastasis,  though  the  x-ray  does  not  show  any  definite 
foci. 

Treatment. — Anodynes  were  ordered  for  the  pain.  Amputation 
would  relieve  the  present  source  of  pain  but  likely  other  foci  will  soon 
appear. 

After-course. — Spontaneous  fracture  took  j^lace  a  few  weeks  later. 
The  pain  in  the  back  has  increased  until  she  is  incapacitated. 

Comment. — "Wlienever  a  patient  has  had  a  malignant  disease  any 
source  of  pain  must  be  assumed  to  be  due  to  metastasis  until  the  con- 
trary is  proved.  Often  fear  deters  patients  volunteering  the  informa- 
tion that  they  have  been  operated  on  for  malignant  disease  until  a 
specific  question  is  put  to  them. 

DISEASES  OF  THE  ELBOW  AND  FOREARM  REGION 

The  affections  of  the  elbow  that  cause  the  surgeon  the  most  trou- 
ble are  the  fractures.  With  the  aid  of  the  x-ray.  which  insures  exact 
diagnosis,  and  the  courage  to  remedy  defects  once  discovered,  this 
chapter  of  surgery  has  lost  many  of  its  annoying  features.  The  oc- 
casional appearance  of  contractures  the  result  of  too  tight  bandag- 
ing reminds  us  to  be  cautious.  The  most  frequently  neglected  dis- 
ease of  this  region  is  the  malignant  tumors.  A  tumor  in  this  region 
that  is  not  a  lipoma  should  be  regarded  as  a  sarcoma  until  negative 
evidence  is  obtained. 

CASE  1. — A  girl  aged  twenty  consulted  me  because  of  a  pulsating 
tumor  in  her  forearm. 

History. — A  year  ago  while  scuffling  with  a  friend  who  was  hold- 
ing an  open  penknife  in  his  hand,  she  received  a  stab  in  the  bend 


388 


CLTXICAL   SURGERY   BY    CASE    HISTORIES 


of  the  elbow.  Six  months  hitcr  a  pulsating-  tumor  developed  in  the 
region  of  the  injury. 

Examination. — The  bend  of  the  elbow  is  occupied  by  a  pulsating 
tumor  3  l\v  6  cm.  The  veins  below  this  region  are  distended  and 
pulsate.  This  seems  to  be  the  cause  of  the  dull  ache  of  which  she 
complains  (Fig.  197). 

Diagnosis. — Distended  veins  which  pulsate  must  be  connected  with 
the  lumen  of  an  artery,  hence  an  arterio-venous  aneurysm. 

Treatment. — The  union  was  between  the  median  or  the  profunda 


Fig.    1?7. — Arterio-venous  aneurysm  showing  the  point  of  union  between  the  artery  and  vein. 

vein  and  the  radial  artery  just  below  the  division.  The  opening  be- 
tween the  artery  and  vein  was  exposed  and  doubly  sutured  by  a  har- 
ness-maker's stitch  with  fine  silk,  and  cut  between. 

After-course. — The  condition  was  relieved. 

Comment. — The  treatment  adopted  was  scientifically  correct  and 
modern,  but  unnecessary.  Ligation  of  both  artery  and  vein  would 
have  secured  good  results. 

CASE  2. — A  merchant  aged  twenty-three  comes  because  of  an  un- 
united fracture  of  the  forearm. 

Ilistorij. — The  patient's  mother  died  of  tuberculosis  three  years 
ago.    Two  sisters  have  died  of  the  same  disease  since  that  time.    The 


DISEASES    OF    THE    UPPER    EXTREMITY  389 

patient  had  tuberculosis  of  the  hip  in  boyhood.  Recovery  followed 
in  three  years  with  a  good  joint,  but  with  2  inches  of  shortening. 
Following  this  bis  health  remained  fairly  good,  but  he  has  periodic 
spells  of  coughing. 

He  fractured  his  ulna  fifteen  months  ago.  Healing  appeared  to 
be  normal.  After  four  months  swelling  without  pain  began.  This 
continued  without  pain  until  four  months  ago  when  the  abscess  was 
opened.  There  was  no  pain  in  the  abscess  before  it  was  incised.  The 
incision  was  made  merely  because  the  doctor  detected  fluid  at  that 
point.     It  has  continued  to  drain  since  that  time. 

Examination. — The  bones  cf  the  arm  are  intact  and  all  movements 
both  active  and  passive  are  unimpaired.  Near  the  center  of  the 
shaft  of  the  ulna  is  a  discharging  sinus.  The  bone  beneath  seems 
thickened.     There  is  no  pain. 

Diagnosis. — A  simple  fracture  which  healed  without  note  followed 
by  a  swelling  terminating  in  pus  production  four  months  later,  without 
pain  or  temperature,  in  a  patient  himself  tuberculous  and  of  tubercu- 
lous heredity,  suggests  the  possibility  of  a  tuberculosis  of  the  shaft 
of  the  bone.  A  suppurative  infection  must  have  expressed  itself 
more  vehemently  long  ago.  Tuberculosis  of  the  shaft  of  long  bone 
is  excessively  rare,  yet  knowing  this  family,  I  felt  sure  that  if  tubercle 
bacilli  ever  had  a  chance  they  had  it  here. 

Treatment. — The  sinus  was  excised  and  the  bone  freed  from  spic- 
ules of  bone  and  a  quantity  of  granulation  tissue.  The  wound  was 
treated  with  carbolic  acid  and  alcohol  and  the  wound  closed. 

Pathologi/. — The  wall  of  the  sinus  showed  several  polynuclear  giant 
cells  with  caseatecl  centers  and  nuclei  located  about  the  periphery, 
evidently  tubercular  giant  cells. 

After-course. — The  wound  closed  without  disturbance  and  has  re- 
mained so  now  nearly  twent}"  years. 

Comment. — This  patient  represents  my  total  experience  with  tu- 
berculosis of  the  shaft  of  the  bone.  The  history  detailed  was  suffi- 
cient to  cause  me  to  suspect  the  proper  diagnosis.  The  attendant 
who  first  incised  the  abscess  made  no  attempt  to  relieve  the  bone 
condition.  Had  the  diagnosis  been  properly  made,  operative  treat- 
ment would  have  been  indicated,  since  conservative  measures  are  less 
necessary  than  when  a  joint  is  involved. 


390  CLINICAL   SURGERY   BY    CASE    HISTORIES 

CASE  3. — A  school  g-irl  aged  seven  was  brought  to  the  hospital 
because  of  a  mass  the  size  of  the  fist  just  below  the  elbow  joint  on 
the  outer  side  of  the  left  forearm. 

History. — Her  parents  noticed  an  enlargement  jnst  below  the  elbow 
the  size  of  a  hazel  nut  about  one  year  ago.  It  grew  very  slowly 
at  first.  In  six  months  it  was  as  large  as  a  walnut.  Since  then  it 
has  grown  more  rapidly.  It  has  never  given  any  pain.  There  is 
no  history  of  previous  injury.  Iler  general  healtli  has  always  been 
good.  She  has  lost  no  weight.  She  had  measles  two  years  ago  and 
mumps  six  months  ago. 

Exaniiiiation. — Patient  has  the  appearance  of  a  perfectly  normal 
child,  rather  large  for  her  age.  There  is  a  mass  on  the  outer  side 
of  the  left  forearm  just  below  the  elbow  about  the  size  of  a  small 
fist.  It  is  firm  but  not  hard  and  seems  movable  in  the  deeper  parts. 
The  superficial  veins  near  and  over  the  tumor  are  very  prominent. 
The  x-ray  shows  the  tumor  to  be  free  from  ossifying  centers  and 
shows  no  attachments  to  the  bones  beneath.  The  tumor  does  throw 
a  denser  shadow  than  the  surrounding  soft  parts  (Fig.  198). 

Diagnosis. — The  location  and  the  rai)id  enlargement  with  ever  in- 
creasing momentum  indicates  that  it  is  malignant.  Such  a  tumor 
could  only  be  a  fascial  or  a  periosteal  sarcoma  and  the  x-ray  as  well 
as  the  mobility  of  the  tumor  declare  the  bones  to  be  free.  Tumors 
of  this  sort  are  incurable  by  any  means.  Local  resection  might  give 
the  little  one  a  few  months  of  bliss,  and  amputation  could  do  but  lit- 
tle more. 

Operation. — The  tumor  was  removed,  taking  most  of  the  skin  cov- 
ering it.  It  was  underneath  the  muscle  and  firmly  adherent  to  the 
capsule  of  the  elbow  joint.  The  capsule  of  the  joint  was  opened  up 
in  removing'  the  mass. 

Pathology. — The  cut  surface  of  the  tumor  is  uniformly  pink  and 
glistening.    The  slide  shows  a  mixed-celled  sarcoma. 

After-course. — The  wound  healed  by  primary  union.  For  the  first 
few  days  there  was  considerable  edema  of  the  hand  and  arm  but  this 
was  gone  by  the  end  of  the  first  week.  Permanent  wrist  drop  is 
present.  She  has  the  power  of  pronation  but  not  of  supination. 
Grip  in  the  left  hand  is  noticeably  weaker  than  in  the  right.  She 
can  extend  and  fiex  the  fingers  and  there  is  no  disturbance  of  sen- 
sation.    She  returned  six  jnonths  later  with  a  metastasis  above  the 


DISEASES    OF    THE   UPPER   EXTREMITY 


391 


site  of  the  operation.    The  patient's  father  suggested  amputation  but 
it  was  refused. 

Comment. — These  fascial  sarcomas  are  always  fatal.  In  the  interest 
of  surgery  any  operation  should  be  refused.  The  x-ray  sometimes 
reduces  them  for  a  time,  at  least  its  use  does  not  add  to  the  patient's 
suffering. 


Fig.    198. — Mixed-celled    sarcoma   of   the    forearm.      The    x-ray    shows    the    growth    to    be    free 

from  the  bones. 


392  CLINICAL   SURGERY   BY    CASE    HISTORIES 


Fig.  199. — X-ray  of  an   osteosarcoma   of  the  forearm  showing  extensive   ossification. 


DISEASES    OF    THE    UPPER    EXTREMITY  393 

CASE  4. — A  farmer  ag-ed  thirty-four  came  for  relief  from  a  tumor 
of  the  forearm. 

History. — He  has  had  a  tumor  on  his  right  arm  for  four  years. 
It  began  as  a  small  growth  in  the  bend  of  his  arm,  the  size  of  the 
end  of  his  thumb.  It  gradually  enlarged  until  it  attained  tlie  size 
of  an  egg.  It  remained  stationary  for  a  time  until  he  injured  it, 
after  which  it  grew  rapidly.  It  is  now  painful  especially  at  night. 
His  general  health  is  good. 

Examination. — A  large  tumor  mass  occupies  the  antecubital  space 
extending  into  arm  and  forearm.  The  x-ray  shows  extensive  ossi- 
fication network  throughout  (Fig.  199). 

Diagnosis. — The  rate  of  growth  and  its  situation  stamp  it  as  a 
sarcoma.  The  x-ray  adds  the  prefix  "osteo."  There  is  no  prospect 
of  a  cure,  but  an  amputation  will  relieve  him  of  a  burden. 

Treatment. — A  shoulder  disarticulation  was  done. 

After-course. — He  regained  his  general  health  and  a  year  after  op- 
eration is  free  from  recurrence. 

Comment. — It  will  come  back. 

CASE  5. — A  man  of  thirty-five  came  for  advice  about  multiple 
tumors  on  his  arms. 

History. — He  does  not  recall  just  when  he  first  noticed  his  tumors, 
but  he  is  quite  sure  they  have  increased  in  both  size  and  number  dur- 
ing the  past  few  years.    They  cause  him  no  trouble. 

Examination. — Distributed  quite  uniformly  along  both  arms  and 
forearm  are  a  number  of  tumors  varying  in  size  from  a  pea  to  a 
walnut  (Fig.  200).  They  are  soft,  attached  to  the  skin,  but  move 
freely  on  the  underh'ing  tissue.  They  are  not  painful  unless  sub- 
jected to  firm  pressure. 

Diagnosis. — Their  uniform  distribution,  their  consistency  and  their 
close  association  with  the  skin  stamp  them  as  neurolipomas.  The 
absence  of  pain  and  the  freedom  of  the  trunk  differentiate  them 
from  Dercum's  disease. 

Treatment. — None  was  advised. 

After-course. — He  remains  in  status  quo. 

Comment. — Occasionally  these  tumors  become  so  large  that  the 
patient  desires  to  get  rid  of  them  for  mechanical  reasons.  Occa- 
sionally, too,  they  are  painful  enough  to  cause  the  patient  to  desire 
their  removal. 


394  CLINICAL  SURGERY  BY   CASE   HISTORIES 


Fig.    200. — Multiple    lipofibrosis    of    the   forearm. 


DISEASES    OF    THE   UPPER   EXTRE:M1TY 


395 


CASE  6. — A  farmer  aged  forty-three  came  to  the  hospital  because 
of  a  swelling'  of  the  elbow. 

History. — He  has  noticed  a  swelling  about  his  elbow  for  about  two 
years.  It  was  not  painful  at  first  but  pains  a  good  deal  now.  Eight 
months  ago  a  doctor  diagnosed  pus  and  made  an  incision ;  only 
blood  escaped.  The  opening  made  did  not  heal  and  the  tumor  began 
to  grow  rapidly  and  a  number  of  ulcers  formed  beside  the  site  of 
incision. 

Examination. — ^A  large  spindleform  mass  occupies  the  site  of  the 
left  elbow.  At  the  top  are  five  defects  in  the  skin  in  which  dark 
reddish,   granular  masses   present    (Fig.   201).     Flexion   is   limited 


Fig.   201. — Sarcoma   of  the  elbow. 

by  the  mass  of  the  tumor,  but  the  joint  surfaces  do  not  seem  to  be 
eroded. 

Diagnosis. — The  situation  of  the  tumor  indicates  that  it  springs 
from  a  tissue  continuous  across  the  joint.  Since  it  unquestionably 
is  a  sarcoma,  it  is  fair  to  assume  that  it  springs  from  a  fascia.  Its 
density  suggests  a  cystic  state,  but  from  the  color  of  the  mass  it  is 
likely  that  a  hemorrhage  has  occurred  in  the  substance  of  a  rapidly 
growing  tumor. 

Treatment. — Exarticulation  of  the  shoulder  joint. 

Pathology. — The  bone  is  free  from  tumor  attachment.  The  tumor 
is  a  mixed-celled  sarcoma  containing  hemorrhagic  areas  near  the 
ulcerous  openings. 

After-course. — He  died  in  fifteen  months  from  visceral  metastasis. 

Comment. — Amputation  in  such  cases  has  for  its  purpose  the  rid- 
dance of  a  mass  which  intoxicates  and  depresses  the  patient.     By 


396 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


SO  doing,  life  is  iiiado  more  pleasurable  and  may  be  prolonged,  but 
they  all  die  from  the  disease. 

CASE  7. — A  girl  of  sixteen  came  to  the  hospital  because  of  a  small 
tumor  on  her  arm. 

History. — As  long  as  she  can  remember  she  has  had  a  small  brown 
spot  on  her  arm  above  the  elbow.  Because  she  regarded  it  as  a  dis- 
figurement, she  had  it  burned  out  with  a  caustic  two  years  ago.  It 
healed,  leaving  a  scar  as  large  as  a  quarter.  During  the  past  few 
weeks  she  has  noticed  the  development  of  a  tinnor  in  the  same  sit- 
uation.   During  the  past  ten  days  it  has  bled  a  little  several  times. 


Fig.    202. — Beginning   melanosarconia   of    the    aim. 

Examination. — Just  below  the  insertion  of  the  deltoid  is  a  soft 
scar  2  x  3  cm.,  near  the  upper  border  of  which  is  a  nodule  the  size 
of  a  hickory  nut  (Fig.  202).  The  whole  surface  is  reddened  and 
near  the  grooved  center  is  a  scab,  the  removal  of  which  causes 
bleeding.  The  tumor  and  scab  are  freely  movable  over  the  under- 
lying fascia.  The  tumor  is  firm  to  the  touch  and  painless  on  manip- 
ulation.    The  axillary  glands  are  not  palpable. 

Diagnosis. — The  appearance  of  a  mass  after  the  cauterization  of  a 
brown  spot  at  once  suggests  a  melanoma  developing  after  the  partial 
destruction  of  a  pigmented  mole.  The  consistency  of  the  tumor, 
together  with  the  tendency  of  the  surface  to  ulcerate,  confirms  this 
opinion. 


DISEASES    OF    THE   UPPER   EXTREMITY  397 

Treatment. — The  scar  with  the  tumor  was  excised,  including  all 
tissue  down  to  the  fascia. 

Pathology. — The  tumor  is  made  up  of  large  cells  containing  large 
nuclei  arranged  in  alveolar  form  with  little  connective  tissue  be- 
tween.   It  is,  therefore,  a  melanoma. 

After-course. — The  patient  has  remained  free  from  recurrence  now 
four  years. 

Comment. — Melanotic  tumors  particularly  those  located  about  the 
shoulder  are  very  prone  to  develop  malignancy  when  irritated,  partic- 
ularly when  the  irritation  is  produced  by  a  cautery.  Wide  excision 
should  always  be  practiced.  When  such  an  area  once  has  shown 
a  disposition  to  grow  a  guarded  prognosis  should  be  given.  No 
matter  whether  there  is  evidence  of  metastasis  or  not,  secondary  tumors 
may  appear  in  after  years.  Microscopic  examination  of  the  tumor 
does  not  assist  in  making  a  prediction.  I  have  seen  hepatic  and  me- 
diastinal tumors  appear  in  cases  where  there  was  no  more  evidence 
than  here  that  such  was  likely  to  take  place.  If  such  metastasis  does 
not  take  place  within  three  years,  there  is  little  likelihood  that  it 
will  occur  at  a  later  date. 

CASE  8, — A  railway  mail  clerk  aged  thirty-two  came  because  of  an 
ulcer  of  his  forearm. 

History. — When  thirteen  years  old  he  was  kicked  in  the  forearm  by 
a  mule.  No  bone  was  broken,  but  the  soft  parts  were  extensively 
bruised.  A  growth  gradually  developed  over  the  bones  raising  up  the 
skin  but  was  not  attached  to  it.     It  continued  to  enlarge  gradually, 


Fig.   203.— Ulcer  of  the  forearm. 


398 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


and  five  years  ago  a  small  place  grew  up  to  the  skin,  l)ut  was  not 
attached  to  it  and  it  was  not  reddened.  If  the  tnmor  was  strnck, 
it  seemed  to  paralyze  his  hand.  He  was  operated  on  soon  after  by 
a  surgeon  Avho  cnt  out  the  growth  and  reunited  the  skin.  The 
wound  healed,  but  a  year  later  the  growth  had  grown  through  the 
skin.  The  tumor,  ulcerated  area  of  skin,  and  all  were  removed  and 
the  skin  again  reunited,  but  healing  did  not  take  place.  He  was 
operated  on  again  a  year  later.  The  hole  was  cut  out  leaving  a 
larger  one.  A  large  ulcer  has  remained  since.  The  border  becomes 
inflamed  and  causes  some  pain,  but  it  is  never  severe.     After  one 


Fig.    204-A. 


-Ulcer    of    the    lorearm.      Thf    tj  u  i  i  inni    cni 
extend  into  the  depth. 


aljiu].itly    with    little    tendency    to 


part  has  pained  for  a  time  it  subsides,  and  some  other  part  begins. 
The  pain  at  no  time  is  severe. 

Examination. — An  ulcer  four  inches  long  by  three  broad  occupies 
the  midportion  of  the  flexor  surface  of  the  forearm  (Fig.  203).  It 
extends  down  to  the  bones.  The  bones  are  covered  by  a  layer 
of  firm  granulation  tissue  and  are  nowhere  bare.  When  the  hand 
is  rotated,  the  bones  move  over  each  other  without  causing  the  pa- 
tient pain.  The  border  of  the  ulcer  is  irregular  with  an  overhanging 
ledge  of  skin  which  shows  some  evidence  of  attempts  at  healing.  In 
some  areas  evidence  of  breaking  down  may  be  seen.  The  ulcer 
is  sensitive  only  on  deep  pressure.     A  thin  secretion  forms  on  the 


DISEASES    OF    THE    UPPER    EXTREMITY 


399 


surface  when  irritated.  It  does  not  bleed  readily  on  manipulation. 
A  section  removed  for  examination  shows  the  epithelial  layer  end- 
ing abruptly  at  the  border  of  the  ulcer  (Fig.  204-A).  There  is  some 
fibrous  tissue  proliferation  and  extensive  round-celled  infiltration 
(Fig.  204-5).  The  vessels  are  somewhat,  but  not  markedly'  thickened. 
Bacterial  examination  fails  to  show  anything  noteworthy.  Repeated 
examinations  gave  negative  Wassermanns. 

Diagnosis. — There  is  no  clue  as  to  the  character  of  the  alleged  tu- 
mor which  was  removed.  The  tumor  has  the  appearance  of  a  Mar- 
jolin's  ulcer.    The  border  does  not  show  any  epithelial  proliferation. 


Fig.    204-i?. — Some   plasma-celled    infiltration,    and   but   little   thickening   of    the   vessels. 


There  is  no  evidence  of  syphilis  and  a  syphilitic  ulcer  does  not  re- 
main stationary  so  long.  If  it  is  not  a  Marjolin's  ulcer  I  do  not 
know  what  it  is. 

Treatment. — Despite  a  negative  Wassermann  he  was  given  salvar- 
san  without  result.  The  x-ray  and  fulguration  has  caused  marked 
improvement  but  not  healing. 

After-course. — By  i)ersistent  use  of  the  x-ray  the  major  portion 
of  the  ulcer  has  healed. 

Comment. — The  first  operator  threw  the  tumor  removed  into  the 
can  and  with  it  the  best  material  for  the  solution  of  the  problem,  I 
am  unable  to  make  a  diagnosis. 


400 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


DISEASES  OF  THE  WRIST 

Tlie  serious  affections  of  this  region  are  diseases  affecting  the  car- 
pal bones  and  the  tendon  sheatlis.  Tlie  most  serious  disease  aside 
from  acute  infections,  is  tu1)erculosis.  Gonorrhea  infections  are 
more  rare.  Fractures  no  longer  cause  perplexity,  thanks  to  Roent- 
gen. 

CASE  1. — A  farmer's  wife  thirty-six  years  of  age,  came  to  the 
hospital  because  of  a  painful  swelling  of  the  hand. 

History. — Fifteen  months  ago  she  noticed  a  swelling  and  some  pain 
when  closing  her  hand.     Later  the  swelling  increased,  but  the  pain 


Fig.  205. —  Tuberculo-sis  of  tt-ndon   sheath. 


decreased.  In  the  past  few  days  the  enlargement  has  been  more  rapid 
and  the  pain  is  greater.  The  patient  knows  no  cause,  and  save  for 
a  maternal  aunt,  she  knows  nothing  of  tuberculosis  in  the  family. 

Examination. — For  a  distance  of  two  inches  or  more  above  the 
palm  is  a  swelling  which  bulges  more  to  either  side  than  in  the  mid- 
line. The  palm  of  the  hand  also  is  more  prominent  than  its  fellow. 
The  tumor  is  elastic,  soft,  and  when  the  mass  above  the  wrist  is 
pressed  in,  that  part  of  the  jialm  becomes  more  prominent,  and 
vice  versa.  Deep  pressure  canses  a  little  pain.  Flexing  the  fingers 
causes  no  pain  unless  the  growth  is  pressed  upon  while  the  fingers 
are  being  flexed.  Upon  deep  pressure  a  grating  is  felt  like  the 
moving  of  several  roughened  bodies  on  each  other.  The  wrist  joint 
seems  free,  an  impression  that  is  confirmed  by  the  x-ray  (Fig.  205). 


DISEASES    OF    THE   UPPER   EXTREMITY  401 

Diagnosis. — A  cystic  mass  appearing  above  the  annular  ligament 
connected  with  one  in  the  palm  is  nearly  always  pathognomonic  of 
tuberculosis  of  the  tendon  sheath.  This  is  doubly  so  when  the  so- 
called  rice  bodies  can  be  palpated.  Ganglions  do  not  grow  so  large 
and  do  not  form  communicating  cysts. 

Treatment. — The  entire  sac  was  dissected  out.  The  anterior  an- 
nular ligament  was  cut  through  and  the  flexor  tendons  dissected 
free  throughout  the  area  involved  by  the  cysts. 

Pathology. — The  contents  of  the  cyst  was  a  glairy  fluid  holding 
in  suspension  many  grayish  pearly  bodies.  The  walls  of  the  cyst 
were  smooth  for  the  most  part,  but  with  some  elevations  in  the 
palmar  portion  of  the  sac. 

After-course. — The  wound  healed  without  incident.  Flexion  of 
the  fingers  was  much  limited  in  the  beginning,  but  persistent  manip- 
ulation restored  nearly  full  function.     Recovery  has  been  permanent. 

Comment. — The  requirements  in  operation  are  that  asepsis  be  main- 
tained and  that  the  operation  be  complete.  If  infection  occurs  or  if 
the  operation  be  incomplete,  disaster  is  likelj'-  to  follow.  The  opera- 
tion should  be  undertaken  only  by  a  skilled  dissector. 

CASE  1-A. — A  matron  aged  thirty-six  was  brought  to  the  hospital 
because  of  an  infection  of  the  forearm. 

History. — For  nine  months  she  has  had  pain  in  the  wrist.  At 
first  it  became  painful  only  on  j)rolonged  use  or  by  some  unusual  or 
violent  movement.  Four  months  ago  she  noticed  a  swelling  in  front 
of  the  wrist.  Her  physician  applied  iodine  which  helped  for  a  time. 
A  month  ago  after  a  violent  wrench  she  had  acute  pain  and  the 
swelling  increased.  She  consulted  a  surgeon  who  diagnosed  pus  and 
made  an  incision.  Some  fluid  she  did  not  see  ran  out  and  she  felt 
better  for  a  few  days.  On  the  fourth  day  after  the  operation  she 
had  a  chill.  The  whole  arm  began  to  swell  and  the  discharge  from 
the  wound  became  more  profuse.  This  has  continued  to  the  present 
time.  The  fever  has  been  constant  and  she  has  no  appetite.  She  does 
not  think  she  has  any  lung  trouble.  She  was  left  an  orphan  at  the 
age  of  six  and  knows  nothing  of  her  family.  She  was  born  in  a 
foreign  country. 

Examination. — The  whole  forearm  is  reddened  and  the  fingers  are 
flexed  in  a  claw-like  manner.  In  the  midline  just  above  the  annular 
ligament  is  an  opening  half  an  inch  long  from  which  a  thin  purulent 


402  CLINICAL    SURGERY   BY    CASE    HISTORIES 

fluid  escapes.  The  lower  half  of  the  forearm  is  swollen,  reddened 
and  very  sensitive  to  the  touch.  The  axilla  and  the  superficial  lym- 
phatics seem  to  be  unaffected.  She  is  thin  and  emaciated  and  there 
is  some  dullness  in  the  left  upper  chest  and  various  sized  rales.  The 
temperature  is  103,  pulse  120,  respiration  28. 

Diagnosis. — She  had  a  synovitis  Avliich  became  infected  after  an 
ill-advised  incision.  The  nature  of  the  synovitis  is  the  problem.  A 
child  born  in  a  foreign  country,  left  an  orphan  at  the  age  of  six 
years  likely  has  a  tuberculous  ancestry.  The  history  of  nine  months' 
duration  substantiates  this.  An  optical  lesion  confirms  it.  Tuber- 
culous tendon  alTections  are  always  serious,  and  when  they  become 
complicated  by  a  mixed  infection  the  gravity  is  much  increased. 
Considering  this,  amputation  seemed  advisable. 

Treatment. — Amputation  four  inches  below  the  elbow  was  done. 

Pathology. — The  wrist  tendons  were  surrounded  by  a  granular  tis- 
sue and  a  moderate  amount  of  free  pus.  The  granulations  showed 
typical  tubercles. 

After-course. — The  wound  healed  without  trouble.  Bacilli  were 
demonstrated  before  she  left  the  hospital.  She  died  six  months  later 
from  a  typical  lung  tuberculosis. 

Comment.— L\ke\y  she  had  a  lung  tuberculosis  before  she  had  the 
wrist  trouble.  It  is  questionable  whether  amputation  is  ever  justi- 
fied because  of  pus  microbal  infection,  but  when  they  are  added  to  a 
preexisting  tuberculosis.  I  believe  such  a  radical  procedure  is  de- 
manded. Incision  of  tuberculous  lesions,  under  a  mistaken  diag- 
nosis of  pus  infection,  is  one  of  the  common  and  most  inexcusable 
errors  observed  in  consulting  practice. 

CASE  2. — A  farmer  aged  twenty-four  came  because  of  a  series  of 
ulcers  on  his  arm. 

History. — He  first  noticed  an  inflamed  area  on  the  back  of  his 
thumb  six  or  eight  weeks  ago.  It  began  as  a  lesion  as  big  as  a  grain 
of  wheat.  It  gradually  enlarged  until  it  was  as  large  as  a  dime.  At 
this  time  he  noticed  a  series  of  lumps  up  his  arm  extending  a  hand- 
breadth  above  the  elbow.  "Within  a  week  these  lumps  reached  the 
surface  and  began  to  ulcerate  and  gradually  to  spread.  The  largest 
above  the  wrist,  is  still  spreading  while  the  remainder  seem  to  be 
stationary.  They  are  but  moderately  painful.  His  general  health 
is  unaffected.     He  states  that  his  brother  is  similarlv  affected  and 


DISEASES    or    THE   UPPER    EXTREMITY  403 

that  tliey  have  been  engaged  in  operating  on  lumpy-jawed  cattle  and 
he  fears  that  they  have  become  infected.  He  has  been  applying  iodine 
at  irregular  intervals  for  several  weeks,  but  has  not  noticed  any  im- 
provement. 

Examination. — Just  above  the  thumb  is  a  lesion  as  large  as  a  dime. 
This,  the  oldest,  is  indurated,  involving  both  the  skin  and  the  deeper 


Fig.   206. — Sporotrichosis   of  arm,    sliowing   characteristic   lesions. 

structures.  It  is  sensitive  on  deep  pressure.  It  appears  as  though 
an  indolent  ulcer  were  lying  just  beneath  the  skin,  gradually  de- 
stroying it.  Above  the  wrist  is  one  as  large  as  a  dollar  (Fig.  206). 
This  extends  less  deeply  in  the  tissues,  does  not  seem  so  dense  on 
pressure,  and  is  less  painful.  On  deep  pressure,  jdus  can  be  made  to 
exude  at  several  points.     Following  a  line  to  the  bend  of  the  elbow 


Fig.    207. — Sporotrichosis,   showing   ulcers   left  after   incision   of   lesions. 

are  six  similar  but  smaller  lesions,  less  deeply  situated  and  less  pain- 
ful. A  series  of  smaller,  more  deeply-seated  lesions  extend  above 
the  elbow  along  the  bicipital  groove  (Fig.  207).  The  axillary  lymph 
glands  are  free  from  ulcers  but  there  are  palpable  glands  that  are 
tender.  Xo  other  part  of  the  body  is  affected.  The  white  blood 
count  was  11,000.     The  pus  obtained  from  the  lesions  was  searched 


404  CLINICAL   SURGERY   BY    CASE    HISTORIES 

for  aetinoinycoses  and  likewise  blastomycoses,  neither  of  which  were 
positively  demonstrated.     Staphylococci  were  present  in  abundance. 

Diagnosis. — The  fact  that  his  brother  was  also  affected  and  that 
they  had  been  operating  on  lumpy-jawed  cattle  made  the  possibility 
of  actinomycotic  infection  the  first  thought.  This  disease  does  not 
travel  along  the  lymphatics  in  this  manner  however.  Sporotrichosis 
follows  the  lymphatics  in  this  manner  but  spores  could  not  be 
demonstrated.  The  development  Avas  too  rapid  for  tuberculous  lym- 
phangitis, though  this  possibility  was  considered  since  it  was  re- 
garded as  possible  that  he  had  been  dealing  with  tuberculous  in- 
stead of  lumpy-jawed  cattle.  The  clinical  appearance  seemed  to 
warrant  a  diagnosis  of  sporotrichosis. 

Treatment. — In  harmony  with  the  presumptive  diagnosis  he  was 
placed  on  20  grains  of  potassium  iodide  three  times  a  day  and  the 
wound  covered  with  boric  acid  ointment.  At  the  end  of  a  week 
no  improvement  was  noticeable.  The  earliest  lesion  was  excised  for 
histologic  examination  and  the  wound  cauterized  with  carbolic  iodine 
aa.     The  proximal  lesions  w^ere  injected  with  iodoform-glycerine. 

Pathology. — The  secretions  obtained  from  the  cut  section  showed 
spores  in  abundance.  Slides  of  the  tissue  removed  showed  a  simple 
granuloma. 

After-course. — After  iodoform-glycerine  had  been  injected  about, 
beneath,  and  into  the  lesions,  they  disappeared  with  amazing  rapidity, 
being  almost  completely  healed  in  a  week. 

Comment. — The  appearance  of  this  lesion  was  pathognomonic. 
Needless  apprehension  was  caused  hy  the  alleged  association  with 
lumpy-jawed  cattle.  Whether  or  not  infections  obtained  about  cat- 
tle are  apt  to  lead  to  sporotrichotic  infections  I  do  not  know,  but  one 
of  the  cases  which  came  under  my  observation  followed  an  injury 
obtained  while  dehorning  cattle.  Some  of  the  lesions  in  this  case 
were  deep,  luring  one  to  a  needless  incision  perhaps,  though  1  am  not 
sure.  After  they  break  down,  it  seems  they  recover  more  quickly 
after  the  escape  of  the  liquid  contents.  Perhaps  it  is  because  the 
remedial  agents  are  then  able  to  come  in  more  direct  contact  with  the 
offending  organism.  Potassium  iodide  internally  and  an  air  exclud- 
ing ointment  locally  usually  suffice  to  cure  these  in  a  few  weeks. 
If  an  indolent  lesion  is  encountered,  it  may  be  speedily  cured  by 
the  use  of  5  per  cent  iodoform  in  glycerine.  The  most  recent  treat- 
ment is  the  use  of  some  one  of  the  aniline  dyes.  Methylene  blue 
is  usually  used. 


DISEASES    OF    THE    UPPER   EXTREMITY  405 

CASE  3. — A  matron  aged  forty-eight  consulted  me  because  of  a 
tumor  of  her  wrist. 

History. — For  ten  days  she  has  had  pain  just  above  her  wrist.  She 
has  some  pain  when  she  closes  her  hand.  A  week  or  so  ago  she  dis- 
covered a  tumor  at  the  site  of  pain.  She  recalls  that  she  struck  her 
hand  against  the  corner  of  a  trunk  before  the  beginning  of  the 
trouble  but  does  not  recall  just  where.  She  states  that  all  her  life 
she  has  had  black  and  blue  spots  from  slight  injuries  that  would  not 
affect  most  people. 

Examination. — The  patient  is  stout,  apparently  in  good  health. 
She  has  prominent  capillaries  in  many  regions  of  her  body.     On  the 


Fig.  20S. — Hematoma  of  the  wrist. 

flexor  surface  of  her  wrist,  three  fingers  above  the  annular  ligament, 
is  a  low  rounded  tumor  (Fig.  208).  It  is  not  definitely  circum- 
scribed, is  boggy  to  the  touch,  and  is  slightly  sensitive  to  pressure. 
It  does  not  move  with  the  tendons,  and  no  friction  is  felt  when  the 
fingers  are  flexed  and  extended.  At  several  points  near  the  circum- 
ference of  the  tumor  the  skin  is  bluish  black  and  at  one  border  is  a 
streak  of  yellowish  green.     Otherwise  the  examination  is  negative. 

Diagnosis. — The  feel  of  the  tumor  is  less  elastic  than  a  cystic  tumor 
connected  with  the  synovial  sheaths  and  the  borders  are  not  well  cir- 
cumscribed. The  tumor  apparently  is  not  attached  to  the  tendons. 
The  fact  that  there  is  a  discoloration  of  the  skin,  that  she  has  been 
subject  to  hemorrhages  following  slight  bruises,  and  that  a  bruise  is 


406  CLINICAL   SURGERY   BY    CASE    HISTORIES 

remembered  to  have  preceded  the  appearance  of  this  trouble  makes 
a  diagnosis  of  hematoma  seem  warranted. 

Treatment. — None. 

After-course. — In  the  week  following  the  yellowish  green  area  ex- 
tended.    In  a  month  she  was  free  from  pain  and  tumor. 

Comment. — Not  infrequently  hemorrhages  about  movable  struc- 
tures cause  reactions  which  for  a  time  simulate  infective  processes. 
The  tenderness  is  less  marked  and  the  local  heat  characterizing  in- 
fections is  absent. 

CASE  4. — A  farmer  aged  thirty-four  came  to  the  hospital  because 
of  a  sv^^elling"  on  the  back  of  the  wrist. 

History. — Several  years  ago  he  noticed  a  small  swelling  on  the 
back  of  his  wrist.  When  he  first  noticed  it,  it  was  as  large  as  a  hickory 
nut  and  caused  pain  only  when  he  used  his  wrist  a  great  deal.  It 
has  gradually  enlarged,  but  has  not  caused  him  any  more  discom- 
fort than  when  it  was  smaller. 

Examination.- — A  soft  cystic  mass  the  size  of  half  an  apple  occu- 
pies the  back  of  his  wrist  (Fig.  209).  It  is  free  from  the  skin  but 
is  deeply  attached.  The  tendons  move  freely  and  there  is  no  limita- 
tion of  the  wrist  joint.  Its  soft  character  and  large  size  indicate 
a  connection  with  the  wrist  joint. 

Diagnosis. — Simple  ganglions  are  smaller  and  harder.  Tubercu- 
lous processes  are  little  likely  to  occur  on  the  back  of  the  hand  and 
since  no  rice  bodies  can  be  felt  in  this  tumor  a  diagnosis  of  hygroma 
can  be  made. 

Treatment. — The  sac  was  liberated  from  the  skin  and  tendons.  In 
making  the  deeper  dissections  the  sac  was  ruptured  and  a  thin,  viscid 
fluid  escaped.     There  were  no  loose  bodies  to  be  found. 

After-course. — Recovery  was  uneventful  and  permanent. 

Comment. — Large  cavities  filled  with  synovial  fluids  go  out  either 
from  tendon  or  joint.  The  same  condition  is  often  observed  in  the 
larger  bursa\  In  this  case  the  cyst  seemed  to  be  in  direct  communi- 
cation with  the  joint.  The  exact  point  of  origin  of  these  tumors  is 
still  a  matter  of  doubt,  some  regard  them  as  springing  from  the 
joint  capsule,  others  from  the  tendon  sheaths,  others,  again,  as  de- 
veloping as  cysts  in  the  paratendonous  connective  tissue.  My  obser- 
vation has  been  that  smaller  ones  are  attached  to  the  tendon  sheaths 
and  the  larger  ones  with  the  joints.     At  least  these  respective  cavi- 


DISEASES    OF    THE    UPPER   EXTREMITY 


407 


ties  are  oj)ened  into  immediately  when  their  removal  is  imdertaken. 
Their  cure  is  best  effected  by  dissection,  though  many  are  cured  by 
aspiration  and  iodine  injection.  In  this  situation  the  use  of  iodine 
is  not  permissible  because  of  the  liability  of  causing  adhesions  about 
the  tendons. 


Fig.    209. — Hygroma    of    the   back    of   the    wrist. 

CASE  4-A. — A  farmer  aged  fifty-eight  came  to  the  hospital  for 
consultation  because  of  a  mass  on  his  thumb  side  of  the  right  wrist. 

History. — About  thirty  years  ago  he  sprained  the  right  wrist  in  a 
scuffle.  He  thinks  the  present  trouble  dates  back  to  this.  The  wrist 
was  somewhat  painful  and  swollen  for  a  few  days  but  soon  com- 


408 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


pletely  recovered.  It  gave  him  no  trouble  until  ten  years  later  after 
a  day's  work  on  a  farm,  during  which  he  used  a  marking  lever  all 
day.  the  Avrist  became  swollen  and  painful  and  remained  so  for  a 
week.  When  the  swelling  went  down,  it  left  a  soft  oval  tumor  in 
the  middle  of  the  back  of  the  right  hand  over  the  middle  finger  ten- 
don. This  gave  him  no  troul)le.  One  year  ago,  after  using  a  post 
digger  all  day.  he  had  severe  pain  in  the  left  hand  and  wrist.  He 
worked  one  more  day  and  then  had  to  stoj)  on  account  of  pain  and 
swelling.  There  was  no  injury  or  abrasion  of  the  skin,  of  any  sort. 
This  continued,  and  four  days  later  a  diagnosis  of  infection  of  the 
hand  was  made.     The  hand  was  opened  by  a  physician  in  the  fol- 


Fig.   210-A. — Nonspecific   granuloma   of   the   wrist. 

lowing  places:  between  the  metacarpal  bones  of  thumb  and  index 
finger  from  dorsal  to  palmar  surface;  over  the  metacarpal  of  mid- 
dle and  ring  fingers  from  dorsal  to  palmar  surface;  over  the  meta- 
carpal bones  of  middle  and  ring  fingers  from  dorsal  to  palmar  sur- 
face, and  along  the  side  of  the  metacarpal  bone  of  the  little  finger. 
The  tumor  on  the  dorsum  of  hand  was  cut  through  and  straw- 
colored  fluid  ol)tained.  Two  days  later  the  hand  and  arm  were 
swollen  to  above  the  elbow  and  a  red  streak  ran  to  the  shoulder. 
The  hand  drained  a  little  ]uis.  The  hand  and  arm  were  kept  in  hot 
packs.  The  wound  healed  in  a])()Ut  30  days  but  a  swelling  remained 
on  the  side  and  back  of  the  right  wrist.  It  has  remained  so  since. 
It  causes  no  pain  now,  but  there  is  a  tenderness  to  pressure  over  the 
lower  inner  part  of  it.    His  general  health  is  good.    It  has  been  di- 


DISEASES    OF    THE   UPPER   EXTREMITY 


409 


agnosed  as  sarcoma  by  three  surgeons  independently,   and  ampu- 
tation was  advised  by  all.    The  Wassermann  was  negative. 

Examination. — The  general  appearance  is  that  of  a  well-nourished 
individual.  Over  the  right  wrist  on  the  thumb  and  dorsal  side  is 
a  rather  dense  mass  extending  from  the  root  of  the  thumb  to  two 
inches  above  the  radiocarpal  joint  (Fig.  210-A) .  It  is  not  ten- 
der, does  not  fluctuate,  and  there  is  no  discoloration  of  the  skin  over 
it ;  the  feel  is  rather  boggy  elastic.     There  are  scars  as  indicated  in 


/^  > 


.•^  ft 


*    ;J>-^,^* *  5,^  fV   i^/T  V' '     ^^  - 


^  '^■ 


I  -!^<(«  ■> 


Fig.   210-B. — Slide   from   a  nonspecific   granuloma   of  the  wrist. 


the  history  from  the  previous  opening.  There  are  several  other 
scars  on  the  dorsal  and  palmar  surface  of  the  hand  not  mentioned 
above.  Flexion  and  extension  of  the  fingers  is  good  but  the  fingers 
cannot  be  tightly  fiexed. 

Diagnosis. — Evidently  he  had  a  recurrent  synovitis.  The  diag- 
nosis of  infection  evidently  was  wrong.  Only  straw  colored  fiuid 
was  obtained  at  this  operation.  The  pus  came  later  and  there  is  no 
doubt  but  that  there  was  then  an  extensive  infection  with  a  lym- 
phangitis. The  Avound  healed,  however.  The  appearance  is  that  of 
a  tuberculosis  of  the  tendon  sheath,  but  these,  once  they  are  cut 


410  CLINICAL   SURGERY    BY    CASE    HISTORIES 

into  and  become  infected,  are  not  prone  to  heal.  Nevertheless,  the 
peculiar  boggy  feel  resembled  nothing  else  so  much  as  tuberculosis. 
A  recurring  attack  of  tuberculosis  would  be  unusual  at  this  time  of 
life,  particularly  in  an  individual  in  such  excellent  general  health. 
He  desires  the  question  of  diagnosis  be  settled  definitely,  since  he 
does  not  like  to  think  of  the  diagnosis  of  sarcoma  already  made.  It 
is  agreed,  therefore,  that  the  tendon  shall  be  freed  from  the  growth. 

Treatment. — The  tumor  was  dissected  from  around  the  dorsal 
wrist  tendon.  An  extensive  dissection  was  required.  The  tendons 
on  the  radial  side  of  the  wrist  were  freed  from  their  sheaths  for 
a  distance  of  four  inches.  The  subcutaneous  fat  was  sutured  over 
and  as  far  as  possil)le  between  them. 

Pathology. — The  tissue  removed  is  a  brownish  red,  firm,  elastic  tis- 
sue. It  is  elastic  and  rolls  under  the  knife  while  being  cut.  It  is  not 
fragile  like  tuberculous  tissue.  It  cuts  like  the  tissue  in  interstitial 
mastitis.  The  slide  shows  many  vessels  with  much  thickened  walls. 
Some  of  the  vessels  are  not  so  thickened  and  have  many  plasma  cells 
about  them.  This  part  of  the  tissue  represents  elephantiasis,  the 
thickened  vessels  .suggest  syphilis  (Fig.  210-7>). 

After-course. — There  Avas  considerable  postoperative  pain  with 
swelling  in  the  lower  arm  and  hand  the  first  twenty-four  hours  fol- 
lowing operation.  This  subsided  and  the  patient  could  flex  the  fin- 
gers witliout  pain  on  the  fourth  day.  The  wound  healed  by  primary 
union  except  at  the  lower  end,  where  it  discharged  some  liquid 
blood.  On  dismissal,  eight  days  after  operation,  the  wound  was 
healed  with  the  exception  of  a  ]ilaee  in  the  incision  1.5  cm.  in  length 
which  was  still  draining  some  bloody  serum.  The  wrist  was  swollen 
and  hard  but  there  was  no  tenderness  to  pressure.  Patient  could  flex 
the  fingers  without  pain,  but  did  not  have  much  wrist  action.  The 
subsequent  report  is  that  the  recovery  has  been  complete  with  little 
impairment  of  function. 

Comment. — Two  expert  patliologists  who  saw  the  slides  suggested 
syphilis  as  the  likely  diagnosis.  The  Wassermann  was  negative, 
however,  and  it  seems  to  me  that  the  best  diagnosis  is  chronic  fil)ro- 
sis  following  an  infected  granuloma.  There  was  no  primary  pus 
formation — that  is  quite  evident.  The  fact  that  the  attending 
physician  hacked  the  hand  in  more  than  half  a  dozen  places  indicates 
that  he  was  working  in  a  Avholly  aimless  manner.  Syphilitic  tissue 
is  not  so  elastic  as  this  and  there  is  no  evidence  of  tuberculosis  either 


DISEASES    OF    THE    UPPER   EXTREMITY  411 

local  or  general.    Likely  if  the  wrist  had  been  mobilized  instead  of 
being  cut  into,  the  pain  would  soon  have  subsided. 

CASE  5. — A  farmer  boy  of  eighteen  came  because  of  a  painful 
swelling'  of  the  wrist  joint. 

History. — For  three  or  four  months  he  has  had  pain  in  his  left 
wrist.  At  first  it  was  noticed  only  at  intervals,  but  recently  pain 
is  present  constantly  on  movement  and  sometimes  there  is  spontaneous 
pain.  For  the  past  several  months  there  has  been  a  gradually  increas- 
ing swelling.  Save  for  tonsillitis  he  has  always  been  well.  There  is 
no  tuberculosis  in  the  family. 


Fig.  211. — Tuberculosis  of  the  wrist  joint. 

Examination. — The  wrist  is  held  stiff  and  the  fingers  are  held  claw- 
like. There  is  a  spindleform  enlargement  in  the  region  of  the  carpal 
bones.  The  forearm  seems  atrophied.  The  wrist  feels  boggy  and  is 
tender  to  pressure.  There  is  voluntary  and  an  involuntary  limita- 
tion of  motion.  There  is  no  crepitation.  The  laboratory  examination 
is  negative   (Fig.  211). 

Diagnosis. — The  gradual  onset,  the  peculiar  enlargement  and  the 
limitation  of  motion  suggest  tuberculosis.  The  onset  is  too  slow 
for  rheumatism  and  it  is  monoarticular.  The  pain  is  not  severe  enough 
and  the  enlargement  too  spindleform  for  gonorrhea.  There  is  no 
evidence  of  a  pus  infection. 

Treatment. — Aspiration  secured  a  few  c.c.  of  a  greenish  yellow  fluid. 


412  CLINICAL   SURGERY   BY    CASE    HISTORIES 

A  5  per  cent  iodoform  emulsion  was  injected  into  the  wrist  joint 
and  repeated  at  intervals  of  three  weeks  for  eight  injections.  Pain 
disappeared  after  a  month  or  two  and  the  swelling  subsided.  A  pal- 
mar splint  was  fashioned  out  of  sheet  steel  and  used  to  immobilize 
the  joint  for  nearly  a  year.  Adhesive  straps  were  used  for  several 
months  longer. 

After-course. — The  recovery  after  two  years  apparently  was  com- 
plete. He  took  up  professional  base  ball  and  played  first  base  for 
a  number  of  years.    Xo  disturbance  in  the  wrist  appeared. 

Comment. — This  evidently  was  a  synovial  tuberculosis.  This  type 
of  trouble  in'  young  persons  may  be  expected  to  respond  satisfac- 
torily to  iodoform-glycerine  injections  with  immobilization. 

CASE  6. — A  boy  aged  four  w^as  brought  to  the  hospital  because 
of  a  tumor  of  the  forearm  which  was  deforming  his  hand. 

Historij. — "When  six  months  old  it  was  noticed  that  there  were 
some  swellings  in  the  left  forearm  above  tlie  wrist.  It  caused  no  in- 
convenience but  grew  slowly.  When  he  was  thre?  years  old  it  was 
noticed  that  the  growth  was  pushing  the  hand  to  one  side.  This  has 
been  particularly  noticeable  in  the  past  three  months.  Aside  from 
this  the  lad  had  always  been  well. 

Examinatio)!. — An  elongated,  bosselated  mass  occupies  the  flexor 
surface  of  the  wrist  from  near  the  ell)ow  to  the  palm  of  the  hand 
(Fig.  212).  It  is  more  prominent  over  the  radial  border  particularly 
at  the  wrist.  The  result  is  an  ulnar  flexion  of  the  hand.  The  tumor 
masses  are  dense,  elastic,  confluent,  and  quite  painless  to  pressure. 
Though  the  hand  is  mechanically  displaced,  the  fingers  can  be  moved 
painlessly  through  a  normal  range.  The  size  is  not  lessened  by 
pressure.     The  skin  and  subcutaneous  tissue  is  not  involved. 

Diagnosis. — Its  early  appearance  and  steady  growth  stamped  it  as 
of  congenital  origin.  Its  dense  elastic  feel  suggests  fluid  within  cavi- 
ties. Since  pressure  causes  no  diminution  of  their  size,  the  vascular 
system  may  be  excluded.  Besides  it  has  the  peculiar  firmness  of 
lymph  cysts,  particularly  notable  in  the  smaller  nodules.  A  caver- 
nous cystic  lymphangioma  was  therefore  diagnosticated. 

Treatment. — The  nodular  mass  was  exposed  throughout  its  entire 
extent.  The  tumor  was  intimately  attached  to  the  sheaths  of  the 
flexor  and  supinator  muscles  and  more  particularly  to  their  tendons. 
The  attachment  in  the  palm  of  the  hand  was  particularly  close.    Here 


DISEASES    OF    THE    UPPER    EXTREMITY 


413 


many  very  small  cysts  were  found  which  could  not  be  palpated 
before.  The  palmar  fascia  was  opened.  The  median  nerve  was 
preserved  with  great  difficulty. 

Pathology. — The  tumor  mass  was  made  up  of  mucous  cysts  which 
when  hardened  were  filled  with  a  firm,  colloid  mass.  The  contents 
of  the  smaller  cysts  were  more  fluid.  The  walls  of  the  cysts  were 
lined  by  a  low  cuboid  epithelium. 

After-course. — Healing  occurred  promptly  and  the  movements  of 
the  fingers  were  preserved.    The  hand  gradually  receded  to  its  prop- 


Fig.  212. — Lymphangioma  of  the  forearm. 

er  position.  Six  months  later  small  cysts  developed  in  the  lower 
portion  of  the  palm  and  in  the  finger.  Since  these  caused  no  in- 
convenience, removal  has  not  been  attempted. 

Comment. — These    are   rare   tumors.      They   do   mischief   only   by 
pressure  and  displacement.     They  are  unaffected  by  x-rays. 


DISEASES  OF  THE  HAND 

Aside  from  infections,  the  surgical  diseases  of  the  hand  are  rel- 
atively unimportant.  Carcinoma  of  the  dorsum  is  the  only  common 
malignant  tumor. 

CASE  1. — A  widow  ag-ed  sixty-four  consulted  me  because  of  an 
ulceration  of  the  thumb  nail. 

History. — A  year  and  a  half  ago,  resulting  from  a  slight  injury  she 
believes,  an  ulceration  began  along  the  outer  border  of  her  left 
thumb  nail.  It  was  painted  with  iodine  and  various  salves  were 
applied  without  result.     After  a  year  the  greater  extent  of  the  nail 


414 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


bed  was  involved  and  the  nail  was  removed.  Despite  this  the 
spreading  contniued.  The  pain  has  never  been  severe,  but  it  hah 
annoyed  her  continually.  Sometimes  there  has  been  a  pronounced 
dull  pain,  particularly  after  she  has  used  her  thumb  more  than 
usual.     Recently  it  has  pained  at  night  and  disturbed  her  sleep. 

Exa-mlnaiion. — The  patient  is  a  well-kept,  motherly  old  lady  who 
regards  her  thumb  with  a  sort  of  mild  satisfied  annoyance.  The  nail 
is  absent,  the  entire  nail  bed  being  occupied  by  a  bluish-black,  granu- 
lar area  showing  here  and  there  islands  of  unatfected  nail  bed  epithe- 
lium and  small  hemorrhages  in  the  more  pronouncedly  affected  parts 


Fig.    213. —  Periungual    melanoma    of    the   thumb. 


(Fig.  21.3).  To  touch  the  nodules  are  firm  and  do  not  tend  readily 
to  bleed  and  are  but  slightly  sensitive  to  light  pressure.  There  are 
no  palpable  h'mph  glands  in  the  drainage  area  and  the  general  ex- 
amination is  negative. 

Diagnosis. — The  slow  spreading  of  a  granular  area  about  the  nail 
bed  suggests  a  periungualitis.  The  obvious  covering  of  epithelial  cells 
and  the  limited  reaction  and  absence  of  secretion  excludes  this.  The 
process  evidently  goes  out  from  a  subepithelial  proliferative  process. 
Its  deep  blue-black  color  suggests  a  melanotic  character. 

Treatment. — Amputation  was  done  at  the  midphalangeal  joint. 

Pathology. — The  section  shows  a  considerable  increase  of  the  epider- 


DISEASES    OF    THE   UPPER    EXTRE:\IITY 


415 


mal  layers  (Fig.  214).  Going  out  from  the  deeper  layers  are  finger- 
like projections  of  cells  which,  have  in  a  measure  undergone  a  change 
in  cell  type  and  tinctorial  reaction  and  there  is  abundant  round-cell 
infiltration.  In  the  connective  tissue  surrounding  these  columns  are 
large  cells  with  prominent  ovoid  nuclei.  Some  of  these  cells  contain 
a  brownish  pigment. 

After-course. — There   has  been   no   recurrence. 

Comment. — The   occurrence  of   a   malignant   growth   about   a   nail 


Fig.    214. — Melanoma    of   the   thumb. 


bed  is  a  distinctly  rare  occurrence.  Its  early  diagnosis  requires  an 
attention  to  detail.  Jonathan  Hutchinson  calls  these  "melanotic 
whitlows"  and  classifies  them  as  sarcomas.  He  regards  them  as  the 
least  malignant  of  the  melanotic  tumors. 

CASE  2. — A  school  girl  aged  nine  was  brought  to  the  hospital 
because  of  a  tumor  of  her  finger. 

History. — For  several  years  it  was  noticed  that  a  tumor  was  de- 
veloping on  her  index  finger.  Lately  the  finger  has  become  deformed. 
Otherwise  her  health  has  always  been  good  and  the  family  history 
is  irrelevant. 

Examination. — The  front  finger  presents  a  tumor  as  large  as  a 
hickory  nut  (Fig.  215).  It  causes  a  deviation  of  the  finger  of  about 
30  degrees.     The  tumor  is  immovable  and  painless  to  pressure.     The 


41G 


CLINICAL    SURGERV    BY    CASE    HISTORIES 


x-rav  shows  the  tumor  to  be  attached  to  the  bone,  but  that  there 
is  a  sharp  line  of  demarcation  between  the  bone  and  the  tumor  and 
also  that  the  tumor  has  a  well  preserved  layer  of  periosteum  covering 
it  (Fig.  216).  The  tumor  itself  is  mottled  with  darker  and  lighter 
areas. 

Diagnosis. — The  well-marked  demarcation  between  tumor  and  bone 
and  the  well-formed  covering  of  periosteum  marks  it  as  a  tumor  fairly 
well  separated  from  the  normal  bone,  and  not  invading  the  surround- 
ing tissue  and  it  is,  therefore,  most  likely  benign.  The  mottling  of 
the  tumor  is  likelv  due  to  an  intermixture  of  cartilage  and  bone. 


Fig.   215. — Enchondroma   of  the  index   finger. 

Treatment. — The  bulk  of  tlie  tumor  was  cracked  off  with  a  mastoid 
chisel  and  the  base  vigorously  curetted  with  a  mastoid  curette.  This 
left  a  base  of  apparently  normal  bone. 

Pathology. — The  tumor  was  made  up  of  bone  structure  well  ap- 
proaching normal  intermixed  with  cartilaginous  areas  which  were 
very  cellular.  There  was  no  evidence,  however,  that  there  was  any 
development  of  the  cartilage  areas  at  the  expense  of  the  bony  areas 
or  soft  parts.  Xo  effort  was  made  to  correct  the  direction  of  the 
finger. 

After-course. — Healing  was  prompt  and  the  relief  permanent. 

Comment. — Bony  tumors  containing  cartilage,  as  well  as  pure  car- 
tilage tumors,  are  always  matters  of  some  concern.    AYhen  such  tumors 


DISEASES    OF    THE   UPPER    EXTRE:MITY 


417 


are  covered  with  bosselations  tlie  size  of  a  wheat  grain  to  that  of  a 
pea  or  larger  it  is  evidence  of  local  independent  proliferation.  These 
are  usually  malignant.  Wlien  the  bone  elements  show  an  arrange- 
ment radiating  from  the  bone,  the  growth  is  likely  malignant.  These 
clinical  data  may  present  a  warning  Avhen  microscopic  study  fails 
to  show  malignancv. 


Fig.    216. — Encliondruma    of    ilie   linger. 


CASE  3. — A  housewife  ag-ed  thirty-six  came  to  the  hospital  be- 
cause of  a  small  growth  on  her  finger. 

Hisforij. — Three  weeks  ago  she  injured  the  second  finger  of  her 
left  hand  with  a  can  opener.  A  little  bleeding  followed  and  the 
fijiger  became  painful.  After  a  week  she  noticed  a  small  tumor  appear 
which  has  continued  to  develop  until  the  present  time.  It  is  less 
sore  than  at  the  beginning. 


m 


CLIXTCAL  SURGERY'   BY   CASE   HISTORIES 


Examination. — A  spherical  tumor  the  size  of  a  large  pea  is  situated 
at  the  outer  border  of  the  root  of  the  nail  (Fig.  217).  It  is  fairly 
soft,  is  hvperemie.  and  is  somewhat  constricted  at  its  base.  The  tis- 
sues about  tlic  hasc  are  not  affected,  neither  is  there  any  extension 
upward. 

Diagnosis. — Its  rapid  development  following  a  trifling  wound,  its 
vascularity  and  well  circumscribed  base  stamps  it  as  a  pyogenic 
granuloma. 

Treatment. — The  tumor  was  excised. 

Pathology. — The  tumor  is  made  up  of  granulation  tissue,  round, 


Fig.    _'l  7. -Granuloma    uf   the    middle    finger. 

plasma  and  polymurpliunuclear  cells  with   iiiany  large  blood  vessels. 

After-course. — In  this,  as  in  all  cases,  local  destruction  was  followed 
by  a  cure. 

Covwient. — These  little  growths  ])eeausL-  of  the  size  of  the  vessels 
and  the  intimate  relation  of  the  cells  to  the  vessels  cause  them  to 
be  mistaken  sometimes  for  more  important  lesions. 

CASE  4. — A  boy  of  twelve  was  brought  to  me  because  of  a  swelling 
of  his  hand. 

History. — AVhen  the  boy  was  a  few  months  old  the  mother  no- 
ticed a  swelling  of  the  outer  border  and  back  of  his  hand.  As  the  boy 


DISEASES    OP    THE   UPPER   EXTREMITY 


419 


grew  this  grew  apace,  and  in  the  past  year  or  so  the  mother  thinks 
it  has  grown  faster  than  tlie  rest  of  the  bo3^  He  has  played  as  other 
boys  and  does  not  seem  to  be  materially  inconvenienced  by  it.  He 
has  no  other  defect  and  has  had  no  disease  of  am'  consequence. 

Examination. — Beginning  proximal  to  the  wrist  a  serpiginous  ele- 
vation may  be  seen  swung  down  toward  the  back  of  the  hand.  Lower 
the  elevations  are  much  more  complex,  so  that  their  identity  is  lost 


Fig.    218-A. — Dorsal    surface    of    angioma   of    the    hand. 


in  the  general  enlargement  (Fig.  218-A).  The  palm  shows  a  thicken- 
ing, but  no  individual  elevations  can  be  made  out  (Fig.  218-B).  He 
flexes  and  extends  the  fingers  and  wrist  without  hindrance.  On  pal- 
pation the  mass  is  felt  to  pulsate  over  the  entire  enlarged  area.  The 
larger  of  the  serpiginous  elevations  pulsates  only  by  transmitted  wave. 
The  entire  mass  may  be  compressed,  but  when  the  pressure  is  re- 
leased the  former  size  is  at  once  resumed. 

Diagnosis. — The  character  of  the  growth  is  made  clear  by  its  com- 
pressibility. The  fact  that  it  pulsates  implicates  the  arterial  sys- 
tem ;  the  large,  nonpulsating  channels  empty  proximately  when  lightly 


420 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


comprossod,  hence  must  be  veins.  It  is,  therefore,  an  arterio-venous 
tumor. 

Treatment. — Both  the  radial  and  ulnar  arteries  were  ligated  an 
inch  and  a  half  above  the  annular  ligament. 

After-course. — Wlien  examined  two  months  later  no  pulsation  was 
present  and  the  mass  had  shrunk  to  a  third  its  former  size.  It  was 
my  intention  to  remove  the  dilated  vessels  at  a  second  sitting,  but 


Fig.  218-B. — Palmar  surface  of  angioma  of  the  hand. 


DISEASES    OF    THE    UPPER    EXTREMITY  421 

the  mother  Avas  so  well  satisfied  by  the  result  that  she  deferred  it. 
Comment. — This  disorder  is  a  congenital  deformity  inasmncli  as 
there  is  no  evidence  that  new  vessels  were  formed  after  birth.  It  is 
to  be  expected  that  as  the  collateral  circulation  is  more  fully  es- 
tablished the  channels  will  become  more  fully  distended.  A  resec- 
tion, therefore,  at  the  maximum  period  of  collapse  is  indicated.  This 
is  usually  in  about  ten  days. 

CASE  5. — A  man  ag'sd  fifty-six  was  broug'ht  to  me  because  of  an 
ulcerative  lesion  of  the  back  of  his  hand. 

Hisforij. — Fifteen  months  ago  he  noticed  a  thickened  scaly  patch 
on  the  back  of  his  right  hand.  It  caused  little  pain  but  it  continued 
to  spread.  He  was  treated  by  x-rays  for  a  number  of  months  and 
the  lesion  healed.  In  three  months  it  reappeared  and  spread  rapidly 
despite  the  use  of  the  x-rays.  It  has  not  been  elevated  as  before  and 
he  thinks  the  border  is  healing.  Two  months  ago  he  began  to  have 
a  swelling  under  the  arm  which  was  painful.  He  does  not  believe  this 
trouble  has  anything  to  do  "with  the  hand  lesion,  because  while  the 
hand  lesion  is  getting  better  the  tumor  under  his  arm  is  more  painful. 

Examination. — An  ulcer  the  size  of  a  dollar  occupies  the  outer 
border  of  the  back  of  the  hand  (Fig.  219).  The  border  for  an  area 
of  4  or  5  mm.  is  bluish  pink,  giving  a  basis  for  the  patient's  belief 
that  the  ulcer  is  healing.  The  base  of  the  ulcer  is  made  up  of  low, 
fairly  firm,  shiny  elevations  which  do  not  bleed  readily  on  touch. 
Here  and  there  dirty  scabs  are  attached  which  when  removed  leave 
small  bleeding  points.  The  ulcer  is  not  attached  to  the  deeper  struc- 
tures, but  can  be  m.ade  to  glide  over  the  tendons.  The  movements  of 
the  fingers  are  not  limited  and  movement  is  not  painful.  There  is  a 
hard,  irregular  mass  in  the  axilla  making  an  aggregate  mass  as 
large  as  a  small  apple.  The  skin  is  red  and  the  tissues  about  it  edem- 
atous. It  is  tender  to  pressure  and  is  attached  to  the  surrounding 
tissue.  It  lies  below  the  axillary  space.  His  general  state  is  undis- 
turbed and  his  leucocyte  count  is  not  abnormal. 

Diagnosis. — From  the  history  and  the  lesion  on  the  back  of  the  hand 
a  diagnosis  may  be  put  down  as  unquestionably  a  carcinoma :  because 
of  the  edema  and  general  evidence  of  reaction,  the  question  of  a  com- 
plicating infection  of  the  axillary  lymph  glands  seems  probable. 
However,  since  the  tumors  of  the  back  of  the  hand  are  prone  to  make 
metastases  which  tend  to  break  cIo^^tl,  judgment  is  reserved. 


422 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


Treatment. — Since  the  axillary  mass  is  causing"  no  constitutional 
reaction  and  there  are  no  signs  of  a  breaking  down,  treatment  is  not 
indicated. 

After-course. — In  a  few  months  the  axillary  mass  broke  down,  pro- 
ducing a  huge  ulcerating  mass,   now   plainly  carcinomatous.      The 


Fig.  1"19. — Carcinoma  of  the  back  of  the  hand. 


hand  ulcer  also  rapidly  extended.     He  died  six  months  later  of  ex- 
haustion. 

Comment. — This  case  illustrated  well  the  capacity  of  tumors  of 
this  sort  to  form  metastases  even  while  the  local  lesion  appears  to  be 
healing.  The  x-ray  is  wholly  untrustworthy  in  the  treatment  of  this 
class  of  tumors  on  the  back  of  the  hand.     AVhen  seen  earlv,  local 


DISEASES    OF    THE    UPPER   EXTREMITY 


423 


excision  ma}"  secure  relief,  but  usually  nothing,  not  even  am]3utation, 
is  able  to  stay  the  course. 

CASE  6. — A  retired  fanner  seventy  years  of  age  came  to  the 
hospital  because  of  inability  to  fully  open  his  hand. 

History. — For  several  years  he  has  been  conscious  of  an  inability 
to  fully  stretch  out  his  fingers.     At  first  the  second  finger  only  was 


Fig.   220. — Dupuytren's  contraction. 

affected,  but  now  others,  particularly  the  little  one,   are  becoming 
affected.    He  has  no  pain. 

Examination. — When  the  patient  presents  his  hand  the  fingers  re- 
main half  closed.  Even  in  this  position  prominent  ridges  may  be 
seen  which  begin  in  the  middle  of  the  palm  and  extend  upward  to 
be  lost  midway  up  the  fingers  (Fig.  220).  When  an  attempt  is 
made  to  forcibly  extend  the  fino-ers,  these  ridges  are  accentuatecj. 


424  CLINICAL   SURGERY   BY    CASE    HISTORIES 

They  are  firm,  liard,  and  scar-like.  The  skin  overlying  them  is  firmly 
adherent  to  their  surface.  The  joints  seem  unaffected.  The  other 
hand  is  free  from  involvement. 

Diagnosis. — The  spontaneous  origin,  the  firm,  scar-like  nature  of 
the  elevation  make  its  recognition  as  a  Dupuytren's  contraction,  clear. 

Treatment. — No  treatment  was  advised. 

After-course. — Contrary  to  the  usual  course,  there  was  no  tendency 
for  the  disorder  to  progress,  neither  did  the  other  hand  become  in- 
volved. 

Comment. — Had  he  been  an  active  individual,  the  operative  cor- 
rection would  have  been  attempted.  The  lesion  was  so  extensive  here 
that  a  complete  removal  of  the  scar-like  tissue  would  have  necessi- 
tated the  removal  of  much  of  the  attached  skin.  That  would  have 
required  skin  grafting.  Since  Thiersch's  grafts  are  not  suitable, 
a  pedunculated  skin  flap  would  have  been  necessary.  This  is  at 
best  an  irksome  procedure,  and  in  an  old  man,  not  without  its  dangers. 
Some  writers  hold  the  view  that  there  is  some  relation  between  Du- 
puytren's contraction  and  gout.  The  patient  was  a  very  tall,  raw- 
boned  pioneer,  little  acquainted  with  the  epicurean  feasts  that  are 
supposed  to  produce  gout. 

CASE  7. — A  farmer  aged  fifty-two  came  to  the  hospital  because 
of  a  disabled  hand  due  to  fracture. 

History. — Seven  months  ago  he  was  thrown  from  a  wagon  and  sus- 
tained a  fracture  of  both  bones  of  his  forearm.  Steel  splints  were 
at  once  placed  on  the  bones.  He  suffered  much  pain  after  the  op- 
eration and  the  hand  swelled.  When  the  cast  was  removed,  he  was 
unable  to  use  his  hand.  Massage  was  applied  but  improvement  did 
not  follow.  It  was  discovered  that  the  bones  had  not  united  and  a 
splint  was  applied.    The  same  condition  applies  at  the  present  time. 

Examination. — The  flexor  muscles  of  the  forearm  are  much  atro- 
phied. There  is  marked  mobility  in  the  lower  third  of  the  radius,  some 
at  the  middle  of  the  ulna.  The  fingers  can  not  be  extended  when  the 
hand  is  extended  but  can  be  extended  when  the  wrist  is  flexed  at 
right  angles.  The  x-ray  shows  a  line  of  separation  in  the  radius,  but 
it  does  not  show  in  the  ulna,  probably  because  the  fracture  is  oblique 
(Fig.  221).     General  examination  is  without  interest. 

Diagnosis. — Evidently  there  is  nonunion  wath  a  Volkmann's  con- 
tracture.    An  operative  procedure  is  required  to  secure  union,  and 


DISEASES    OF    THE   UPPER   EXTREMITY 


425 


Fig.   221. — Ununited  fracture   of  both  bones   of  the   forearm. 


426  CLINICAL   SURGERY   BY    CASE    HISTORIES 

while  this  is  being'  doni%  the  bones  ean  l)e  shortened,  thns  viearionsly 
lengthening  the  flexor  tendons,  permitting  extension  of  the  fingers 
with  the  hand  extended. 

Treatment. — The  steel  plates  were  removed  and  llie  ends  of  the 
fragments  removed  so  as  to  shorten  the  bones  about  five-eighths  of 
an  inch.  The  ends  of  the  bones  were  brought  together  with  bone 
pegs  but  without  plates. 

After-course. — Union  occurred  promptly.  The  fingers  could  be 
extended  as  was  planned,  but  flexion  was  not  restored  because  the 
muscles  would  not  contract. 

Comment. — It  now  occurs  to  me  that  the  state  of  contractility  of  the 
muscles  had  not  been  studied  with  sufficient  detail.  They  were  ob- 
viously converted  into  fibrous  tissue  hj  a  fibrosing  myositis,  whether 
due  to  the  trauma  of  the  operation  or  from  the  cast,  I  do  not  know. 
Obviously  the  lengthening  of  the  tendons  can  be  of  no  service  if  the 
muscles  have  lost  their  capacity  to  contract.  If  the  myositis  is  local, 
leaving  a  part  of  the  muscle  capable  of  contraction,  operative  pro- 
cedures may  be  of  avail.  In  a  case  of  this  sort  with  the  wrist 
flexed  and  the  fingers  extended,  forcible  flexion  of  the  fingers  is  not 
possible,  operation  is  useless.  It  has  not  been  sufficiently  emphasized 
that  there  is  a  difference  between  a  localized  mj'ositis  due  to  a  cut  or 
a  gunshot  Avound  and  one  in  which  the  entire  muscle  is  destroyed 
from  compression,  a  true  Volkmann's  contracture.  In  this  case 
judging  from  the  length  and  sites  of  the  scars  and  the  inexperience 
of  the  operators,  it  is  quite  lilvcly  that  the  myositis  was  due  chiefly 
to  operative  traumatism. 

CASE  8. — A  merchant  aged  thirty-six  came  because  of  stiffness 
of  his  fingers. 

Historij. — A  year  ago  he  injured  his  left  index  finger  while  driving 
a  tack.  He  was  not  annoyed  until  the  morning  of  the  third  day. 
At  this  time  the  finger  became  painful  and  began  to  throb.  He 
began  to  feel  sick  all  over  and  to  lose  his  appetite.  The  inflamma- 
tion spread  rapidly  and  he  had  a  fever.  On  the  seventh  day  his 
physician  made  an  opening  in  the  finger  near  the  point  with  a  sharp 
knife  after  freezing  the  skin.  Some  pus  escaped  and  the  finger  felt 
easier,  Init  the  swelling  extended  above  the  wrist.  He  was  given 
an  anesthetic  and  the  hand  was  opened  in  four  places  and  a  tube 
drawn  through  the  palm  to  the  back  of  the  hand.     Pus  discharged 


DISEASES    OF    THE    UPPER   EXTREMITY 


427 


freely,  and  the  pain  was  someAvhat  relieved.  Four  days  later  lie  was 
given  another  anesthetic  and  several  openings  were  made  above  the 
wrist.  All  these  various  openings  discharged  pus  for  several 
months,  then  they  healed  one  after  the  other.  The  hand  remained 
much  swollen  and  he  could  not  move  his  fingers.  He  bathed  his 
hand  in  hot  water  and  had  it  rubbed.     The  swelling  gradually  went 


Fig.  222. — I,ate  result  in  a  ca.se  of  palmar  infection  inadequately  drained. 


428  CLINICAL   SURGERV    BY    CASE    HISTORIES 

down,  but  the  fingers  became  drawn.  At  no  time  was  he  able  to 
bend  them.  He  is  now  free  from  pain,  but  save  for  slight  movement 
of  the  thumb,  the  fingers  are  motionless.  His  physician  advises  him 
to  have  the  tendons  lengthened.  His  general  health  has  always  been 
good.  During  the  time  the  hand  was  inflamed  he  had  an  attack  of 
articular  rheumatism.  The  left  knee  and  the  ankle  joints  were 
most  affected. 

Examinaiion. — The  hand  is  claw-Iiko.  the  fingers  Ijeing  held  rigid 
by  sear-like  contractions.  These  cannot  be  extended  or  flexed  either 
by  the  patient  or  by  the  examiner.  The  small  muscles  of  the  hand 
are  all  atrophied.  The  feel  of  the  fingers  Avhen  one  attempts  to  ex- 
tend them  reminds  one  of  a  Dupuytren's  contraction  (Fig.  222). 
The  wrist  can  be  slightly  flexed.  No  less  than  thirteen  small  scars 
can  be  counted  where  small  punctiform  openings  had  been  made. 

Diagnosis. — Oljviously  the  tendons  became  irreparably  damaged 
during  the  prolonged  suppurating  process.  The  contractures  are 
due  to  scar  formation  in  the  granulations  arising  in  the  inflamma- 
tory area.  Most  likely  the  tendons  largely  liquefied  and  were  ex- 
truded.   Nothing  can  be  done  to  restore  the  function  of  the  fingers. 

Treatment. — None. 

After-course. — There  has  been  no  change. 

Comment. — There  is  but  one  operation  that  cannot  be  done  under 
local  anesthesia  :  the  opening  of  an  infected  hand.  Whenever  there 
are  multiple  openings  one  knows  at  once  that  the  operator  is  timid 
or  incompetent,  most  likely  timid  because  incompetent.  This  hand 
should  have  ])een  incised  from  the  tip  of  the  finger  to  the  annular 
ligament  at  tlie  time  the  first  punctiform  incision  was  made. 

CASE  9. — I  was  called  to  see  a  business  man  aged  thirty-four  be- 
cause of  an  infected  hand. 

History. — Four  days  ago  he  injured  the  tip  of  his  right  index 
finger.  The  next  morning  he  had  pain  and  the  finger  was  swollen. 
He  applied  a  bichloride  pack,  the  pain  and  swelling  continued,  and 
the  whole  forearm  and  hand  was  placed  in  a  hot  water  pack.  His 
pain  increased  and  he  had  fever  as  high  as  104°.  Last  night  he  had 
a  muttering  delirium  most  of  the  night. 

Examination. — The  hand  is  twice  its  normal  thickness.  The  palm 
bulges  and  the  dorsum  is  edematous.    The  flexor  surface  is  hard,  red, 


DISEASES    OF    THE   UPPER   EXTREMITY  429 

and  edematous  to  within  a  handbreadtli  of  the  elbow.  He  had  a 
temperature  of  102°,  pulse  130,  and  respiration  28. 

Diagnosis. — The  palm  is  tense  and  elastic.  The  forearm  is  like- 
wise tense  and  hard,  indicating  involvement  high  above  the  wrist. 
General  intoxication  is  extreme  and  wide  opening  is  needed. 

Treatment. — Under  ether  an  incision  was  made  from  the  tip  of  the 
index  finger  to  the  annular  ligament.  The  ligament  was  spared,  but 
the  skin  incision  was  continued  to  the  junction  of  the  inflamed  and 
normal  skin,  about  3  inches  from  the  elbow.  The  tendons  were  ex- 
posed and  were  found  bathed  in  pus.  There  was  pus  between  the 
profound  and  sublime  flexors  of  the  forearm.  The  whole  wound  was 
loosely  packed  with  gauze. 

After-course. — The  temperature  subsided  in  a  few  days.  In  a 
month  the  wound  was  covered  with  granulations  and  the  edges  Avere 
approximated  by  adhesive  strips.  In  another  month  the  wound  was 
almost  completeh^  healed.  He  had  good  function  in  about  six 
months. 

Comment. — Bold  action  was  required  here  in  order  not  only  to 
save  the  hand,  but  even  the  life  of  the  patient.  In  limited  infections 
above  the  wrist,  transverse  drainage  is  preferable,  but  in  such  ex- 
tensive infections  in  the  forearm  a  wide  split  in  the  midline  is  pref- 
erable. The  split  in  the  tissues  must  in  all  cases  be  so  extensive  that 
the  edges  lie  apart  of  their  own  accord. 


CHAPTER  X 

DISEASES  OF  THE  LOWER  EXTREMITIES 

The  diseases  of  the  lower  extremity  are  most  commonly  those  that 
have  to  do  Avith  fiiuetion.  Diseases  dangerous  to  life  are  mostly  neo- 
plastic and  the  vast  majority  of  these  are  sarcomatous.  Infections 
are  less  common  than  in  the  arm.  The  painful  atfections  are  pre- 
ponderatingly  inflammations  of  the  joint  and  synovial  surfaces. 
The  painful  affections  concern  often  the  great  sciatic  nerve,  but 
the  primary  disease  is  usually  some  joint  surface. 

DISEASES  OF  THE  HIP 

Affections  of  the  hip  are  chiefly  tuberculous :  Pershing's  disease; 
septic  ai'tliritis  and  coxa  vara  in  tlie  young;  fracture  aiul  hyper- 
plastic arthritis  in  those  of  more  advanced  years.  Affections  of  the 
bursje  and  referred  pains  are  less  common. 

CASE  1. — A  physician  aged  forty  consulted  me  because  of  a  pain- 
ful bruise  of  his  hip. 

History. — The  patient  was  thrown  from  a  street  ear,  lighting 
squarely  on  his  hip.  The  hip  was  painful  but  he  continued  his  journey, 
and  save  for  a  soreness  he  got  about  very  well  for  a  few  days.  The 
pain  became  more  intense,  particularly  on  movement,  not  only  by 
the  act  of  locomotion,  but  by  the  jarring  of  a  conveyance.  The  pain 
involved  the  region  of  the  hip.  but  was  particularly  severe  over  the 
trochanter.  Pressure  over  the  neck  of  the  fcnuir  in  frf)nt  increased 
the  pain.  The  pain  on  movement  was  acute  and  lancinating  so  that 
on  making  certain  movements  he  would  nearly  collapse.  An  x-ray 
was  taken,  but  failed  to  show  any  lesion.  A  month  after  the  injury, 
the  pain  still  continues  without  notable  abatement. 

Examination. — The  patient  as  ccmipared  to  his  former  self  looks 
haggard  and  has  lost  twelve  pounds  in  weight.  The  chief  point  of 
tenderness  is  below  and  behind  the  great  trochanter.  Tenderness  over 
the  joint  is  elicited  only  when  the  soft  parts  of  this  region  are  pulled 
on.     Flexion  and  outward  rotation  causes  great  pain.     There  are  no 

430 


MSEASES    OF    THE    LOWER    EXTREMITIES 


431 


constitutional  distnrbanees,  the  loss  in  weight  being  due  apparently  to 
the  suffering  incident  to  the  attempt  to  meet  the  requirements  of  his 
practice  while  undergoing  great  suffering. 

Diagnosis. — The  character  of  the  suffering,  the  nature  of  the  in- 
jury, and  the  points  of  maximum  tenderness  stamp  this  as  an  inflam- 
mation of  the  subgluteal  bursa.     A  week  later  a  distinct  swelling  in 


Fi.£ 


-Hydrops    of   the   subgluteal   bursa. 


this  region  appeared  (Fig.  223)  which  when  aspirated  yielded  an 
ounce  of  straw-colored  fluid. 

Treatment.— At  the  first  visit  the  painful  area  was  tightly  strapped 
with  adhesive  which  gave  considerable  relief.  After  the  exudate  ap- 
peared, aspiration  was  done  and  the  adhesive  replaced. 

After-course. — Seme  pain  remained  for  some  months  but  this  dis- 
appeared and  there  was  no  recrudescence. 

Comment. — These  affections  are  more  common  than  diagnosed,  the 
pain  generally  being  ascribed  to  inflammations  of  the  joint  capsule. 


432 


CLINICAL   RUROKRY   BY    CASE    HISTORIES 


Because  of  the  dei)tli  of  the  bursa  the  location  of  the  inflamination 
may  be  difficult  to  establish.  An  injection  of  quinine  urea  hydro- 
chloride four  drams  of  a  1  per  cent  solution  is  more  effective  than  the 
treatment  used  in  this  case, 

CASE  2. — A  farmer  lad  was  brought  to  me  because  of  pain  in  the 
left  hip. 

History. — His  general  health  has  always  been  good.  He  has  done 
the  manual  work  of  the  farm.  He  remembers  no  injury.  He  has 
always  been  Avell  until  one  year  ago  when  he  noticed  a  pain  in  the 
left  hip.  The  pain  grew  more  intense  despite  counterirritants,  and 
in  the  last  few  months  he  has  noticed  a  pain  in  the  left  thigh.  In 
the  last  few  months  he  has  noticed  a  gradual  impairment  of  motion. 


A.  B. 

Fig.   224. — Co-xa  \"ara.     A   slio\v.s  direction   (if  neck   in   this   case.      B,   the   normal. 

His  mother  has  a  myoma  of  the  uterus  and  a  brother  has  a  mitral 
stenosis  following  rheumatism. 

Examination. — The  patient  is  large  for  his  age  and  his  bony  frame- 
work is  correspondingly  massive.  His  hands  and  feet  are  cold  and 
cyanosed  and  his  general  musculature  is  somewhat  flabby.  The  knee 
shows  the  marks  of  rigorous  counterirritation.  The  leg  is  rotated 
outward  and  crosses  the  midline  of  the  body.  An  attempt  to  ab- 
duct the  leg  meets  with  a  sudden  limitation  before  its  axis  becomes 
parallel  with  that  of  the  body.  Attempts  at  internal  rotation  like- 
wise receive  a  sudden  check  as  soon  as  the  foot  reaches  the  vertical. 
The  rotation  outward,  on  the  contrary,  and  adduction  are  not  limited. 
Extension  is  not  limited  and  flexion  but  slightly  so.  There  is  some 
fullness  in  Scarpa's  triangle  and  some  tenderness  at  this  point.  As 
the  leg  is  flexed  on  the  thigh  and  the  thigh  on  the  trunk  the  foot 
automatically  crosses  the   midline   of  the   body  toward  the  unaf- 


DISEASES    OF    THE    LOWER    EXTREMITIES  433 

fected  side.  The  affected  limb  is  94  cm.  long  while  its  fellow  is  2  cm. 
longer.  There  is  no  muscular  tension  anywhere  and  no  pain  unless 
an  attempt  is  made  to  force  the  range  of  motion  beyond  the  limits 
above  described  (Fig.  224). 

Diagnosis. — Limitation  of  abduction  and  internal  rotation  is  char- 
acterized by  a  bending  downward  of  the  neck  of  the  femur,  as  evi- 
denced by  the  shortening  of  the  leg,  therefore  a  coxa  vara.  Since 
there  is  no  history  of  trauma,  it  must  be  classed  as  of  the  static  type. 

Treatment. — The  patient  was  placed  in  bed  and  a  weight  of  eight 
pounds  attached  to  his  leg. 

After-course. — The  treatment  lessened  the  pain  but  did  nothing 
toward  correcting  the  deformity.  After  three  months '  trial  the  treat- 
ment was  abandoned.  He  was  examined  recently,  tifteen  years  after 
the  onset  of  the  trouble,  and  while  the  deformity  remains,  he  has  no 
pain  and  is  not  inconvenienced,  save  that  he  finds  it  impossible  to 
ride  a  horse. 

Comment. — The  result  of  treatment  in  the  cases  I  have  observed 
since  that  time  has  been  about  the  same.  If  there  is  pain,  extension 
will  sometimes  relieve  it.  I  have  never  seen  the  deformity  increase 
while  under  observation  or  decrease  under  treatment,  and  I  have 
come  to  believe  that  a  division  of  the  cases  into  static  and  traumatic 
is  purely  an  academic  one. 

CASE  3. — A  laborer  of  twenty-six  came  to  the  hospital  because 
of  pain  in  the  hip. 

History. — Ten  years  ago  after  being  sick  for  a  week,  with  an  ail- 
ment which  his  phj'sician  did  not  name,  while  walking  up  town  he 
became  suddenly  very  sick.  He  remembers  nothing  save  that  he 
felt  very  sick  and  had  a  tendency  to  fall  over  backwards.  He  re- 
mained in  bed  a  few  days  only  and  while  again  walking  up  town 
he  felt  a  sudden  pain  in  his  right  hip,  most  severe  on  the  inner  side. 
He  was  able  to  walk  home  but  he  remained  in  bed  six  weeks.  He 
was  constantly  under  his  doctor's  care  but  was  never  told  the  nature 
of  his  trouble.  After  this  he  was  able  to  do  farm  work,  but  the  pain 
never  left  the  hip  and  a  year  later  the  pain  became  so  severe  that  he 
again  remained  in  bed  six  weeks.  He  went  to  work  again  but  was  in 
constant  pain.  Some  time  after  this  he  had  a  sudden  pain  in  the  hip 
attended  by  severe  pain  in  the  inner  side  of  the  knee.  These  inter- 
mittent pains  continued  vdthout  change  for  several  years  and  after 


434 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


about  four  years  he  noticed  that  the  muscles  of  this  thigh  had  shrunk. 
This  state  existed  until  two  months  ago  when  he  slipped  in  going 
down  a  basement  steps.  He  kept  himself  from  falling  entirely  down 
by  catching  the  railing.  He  wrenched  his  hip,  however,  and  the 
pain  became  so  severe  that  he  had  to  use  crutches  afterward.  For  the 
past  few  weeks  he  is  able  to  get  along  without  them,  but  the  pain  is 


Fig.  225. — Exostosis  on  articula  head  of  the  femur. 


DISEASES   OF    THE   LOWER   EXTREMITIES  435 

severe,  particularly  if  he  attempts  to  carry  any  load.  There  has 
never  been  any  swelling  in  the  hip  that  he  knows  of.  He  had  a  fever 
during  the  first  spell  with  his  hip  but  he  does  not  know  whether  he 
had  any  during  his  first  illness  or  with  the  subsequent  attacks  with 
his  hip.  He  had  whooping  cough  as  a  child  and  smallpox  a  year  ago, 
but  he  has  not  had  typhoid,  rheumatism,  or  tonsillitis.  His  general 
health  has  always  been  good. 

Examination. — The  patient  is  a  husky  young  man  who  bears  no  evi- 
dence of  suffering  or  general  ailment.  His  tonsils  are  injected  and 
ragged  and  he  has  a  pyorrhea  of  his  lower  front  teeth.  Heart  and  lungs 
are  negative.  The  legs  are  of  equal  length.  The  reflexes  are  normal 
and  there  is  no  difference  in  musculature  though  the  right  thigh 
and  leg  are  an  inch  less  in  circumference.  Abduction  is  limited,  but 
internal  rotation  is  not.  External  rotation  causes  some  pain  when 
forced.  The  x-ray  shows  an  irregular  acetabulum  and  femoral  head 
(Fig.  225).  At  the  upper  border  of  the  articular  surface  is  an 
exostosis  which  apparently  is  the  cause  of  the  limited  abduction  and 
pain.     All  laboratory  examinations  are  wholly  negative. 

Diagnosis. — The  initial  disease  can  not  be  determined  with  cer- 
tainty. One  may  suspect  tonsillitis.  His  sudden  sickness  and  ten- 
dency to  fall  backward  was  probably  due  to  general  circulatory 
changes.  At  any  rate  they  were  fleeting  and  no  focal  lesion  appears 
to  have  developed.  If  a  thrombotic  process  was  present,  it  was  of 
temporar}'  importance  only.  The  pain  in  the  hip  may  have  been 
secondary  to  some  other  lesion  or  may  have  been  primary  and 
the  cause  of  his  primary  sickness.  Be  this  as  it  may,  with  the  ap- 
pearance of  pain  in  the  hip  the  picture  becomes  clear.  It  is  that  of 
a  coxitis  with  referred  pains  in  the  region  of  the  knee.  Though  this 
never  came  to  actual  suppuration,  exudative  processes  evidently  were 
sufficient  to  produce  changes  in  the  articular  surfaces  of  the  head  of 
the  femur  and  in  the  joint  surfaces  coming  in  contact  with  it.  The 
only  mechanical  limitation  is  that  of  abduction.  There  is  evidence 
of  bony  overgrowth  at  the  upper  border  of  the  acetabulum.  Move- 
ments in  other  directions  seem  to  cause  no  pain.  It  seems  likely, 
therefore,  that  the  removal  of  this  part  may  overcome  his  disability 
and  permit  one  to  secure  the  offending  lesions  which  from  the  pro- 
longed course  of  the  disease  must  lie  within  the  bone. 

Treatment. — The  hip  joint  was  exposed  by  an  incision  from  the 
crest  of  the  ilium  over  the  highest  point  of  the  great  trochanter.    An 


436  CLINICAL   RUROERY   BY    CARE    HIRTORIES 

exostosis  was  inicoverod  on  tlio  border  of  the  articular  surface  of 
the  head  of  tlie  femur,  larger  than  one  expected  from  the  x-ray  pic- 
ture. This  Avas  remoYed  \Yith  the  chisel.  The  edge  of  the  acetab- 
ulum had  many  excrescences  and  these  likewise  were  removed.  This 
done,  there  seemed  to  be  no  limitation  to  the  movements  of  the  joint, 
neither  was  there  any  grating  to  be  felt  as  the  manipulations  were 
carried  out.  The  neck  of  the  femur  was  opened  into  and  a  cavity  as 
large  as  a  small  hickory  nut  was  found.  This  was  filled  with  a 
rather  firm  granular  material  which  came  out  en  masse  Avhen  loos- 
ened Avith  the  curette.  The  cavity  was  thoroughly  gouged  out  and 
iodine  applied.  The  joint  capsule  was  closed  with  20-day  chromic 
catgut  and  the  soft  parts  in  layers  with  pyoktanin  gut. 

Pafliologij. — The  bone  removed  had  an  irregular  eliurnated  sur- 
face, but  the  cartilage  was  nowhere  defective  and  the  center  was 
composed  of  cancellated  bone.  The  granular  material  obtained  from 
Avithin  the  neck  showed  no  bacteria  and  was  made  up  of  Avell-organ- 
ized  granular  material,  the  walls  of  the  vessels  being  thick  Avith 
hyaline  changes  and  the  round  cells  were.  few. 

After-course. — The  leg  Avas  kept  in  position  Avith  sand  bags;  neither 
weights  nor  splints  Avere  used.  The  leg  Avas  moved  early  and  he 
Avas  about  on  crutches  in  tAvo  AA'^eeks  and  Avas  allowed  to  lea\'e  the  hos- 
pital on  the  seventeenth  postoperative  day. 

Comment. — From  the  nature  of  the  granulation  tissue  it  seems 
likely  tliat  the  first  attacks  of  pain  only  Avere  due  to  the  infectious 
process,  the  subsequent  difficulty  being  due  to  the  results  of  the  early 
proliferation.  That  the  Avhole  disease  Avas  due  to  a  central  focal 
infection  of  a  source  unknoAvn,  there  can  be  but  little  doubt. 

CASE  4. — A  school  boy  ag-ed  eighteen  Avas  brought  to  the  hospital 
because  of  pain  in  the  hip. 

History. — Aside  from  frequent  attacks  of  tonsillitis  he  has  had 
fair  health.  Two  years  ago  he  fell  from  his  bicycle,  striking  on  his 
left  hip.  It  felt  bruised  for  some  days  but  he  continued  to  ride  his 
bicycle  as  before.  A  year  later  he  began  to  ha\^e  pains  in  the  hip 
which  gradually  increased  until  he  Avas  no  longer  able  to  ride.  The 
pain  AA'as  most  severe  AA'hen  the  thigh  Avas  flexed  to  the  extreme  point 
in  pedaling.  He  rode  the  street  cars  to  AA^ork  for  some  months  but 
gradually  the  pain  became  too  great  to  permit  Avalking  for  more  than 
short  distances  and  soon  he  Avas  no  longer  able  to  remain  at  Avork. 


DISEASES   OF    THE   LOWER   EXTREMITIES 


437 


Examination. — The  boy  is  somewhat  pale  and  undernourished,  but 
examination  outside  of  the  hip  showed  no  abnormalities.  The  left 
thigh  is  2  cm.  less  in  circumference  than  its  fellow.  There  is  no 
shortenino-.     Internal  rotation  and  adduction  is  limited  as  is  flexion. 


Fig.   226. — Infective  arthritis   of   the  hip  joint. 


Attempt  to  exceed  the  acceptable  range  causes  pain.     There  is  no 
roughening  apparent  on  passive  movement. 

Diagnosis. — The  free  abduction  excludes  coxa  vara  though  the  lim- 
ited internal  rotation  suggested  it.     The  lack  of  shortening  also  spoke 


438  CLINICAL   SURGERY   BY    CASE    HISTORIES 

against  coxa  vara.  The  location  of  the  j)aiii  and  the  manner  of  onset 
and  the  age  of  the  patient  argued  against  tuberculosis  though  this 
seemed  a  possibility.  The  x-ray  alone  could  decide  the  matter  (Fig. 
226).  The  radiogram  showed  a  marked  lipping  of  the  lower  border 
of  the  head  and  some  roughening  of  the  articular  surface  on  the 
lower  half.     An  infective  arthritis  seemed  the  proper  diagnosis. 

Treatment. — The  patient  was  placed  in  a  cast  which  was  changed 
at  intervals  of  two  montlis.    The  tonsils  were  removed. 

After-course. — At  the  end  of  a  year  he  was  free  from  pain  and  got 
about  very  well,  but  there  was  still  the  lipping  of  the  head  of  the 
femur  and  some  limitation  of  movement. 

Comment. — Chronic  arthritic  changes,  particularly  of  the  milder 
degrees  are  often  overlooked  in  young  persons.  When  present,  fixa- 
tion is  the  best  treatment,  as  it  gives  the  necessary  rest. 

CASE  5. — A  matron  of  sixty  came  to  the  hospital  because  of  pain 
in  the  hip  joint. 

History. — Four  years  ago  she  fell  down  a  flight  of  stairs  but  got 
up  and  walked  about  without  much  difificulty.  A  day  later  she  be- 
gan to  have  pain  in  the  right  hip.  It  was  not  severe  at  first  and  she 
paid  little  attention  to  it,  but  it  gradually  grew  worse  and  for  the 
past  year  it  has  been  severe.  The  pain  extends  along  the  inner  side 
of  the  thigh  to  the  knee  and  along  the  back  of  the  leg  to  the  foot. 
There  is  some  shrinking  of  the  muscles  and  shortening  of  the  leg  for 
the  past  two  years  she  thinks.  The  pain  is  increased  by  being  on  her 
feet  a  good  deal  and  is  worst  in  the  act  of  sitting  down.  She  had 
whooping  cough  in  childhood  and  had  freriuent  attacks  of  tonsilli- 
tis ujD  until  9  years  ago.  Her  general  health  is  good,  but  she  is 
annoyed  sometimes  by  bladder  irritation.  She  has  had  four  healthy 
children  and  no  miscarriages. 

Examination. — She  appears  a  well-nourished,  contented  person, 
well  preserved  for  her  years.  Heart  and  lungs  are  negative  and  the 
tonsils  are  atrophic.  When  she  lies  on  the  table  the  right  malleolus 
lies  two  inches  higher  than  its  fellow.  Measurements  show  this  to  be 
due  to  tilting  of  the  pelvis.  The  alleged  atrophy  of  the  muscles  could 
not  be  substantiated.  The  movements  of  the  hip  joint  were  limited, 
particular]}"  abduction.  All  movements  caused  more  or  less  pain. 
The  extremes  caused  a  grating  feeling.  The  x-ra}'  shows  an  irregu- 
lar articular  surface  with  many  pronounced  exostoses  (Fig.  227).    Her 


DISEASES   OF    THE   LOWER   EXTREMITIES 


439 


blood  pressure  is  162-100.     The  urine  is  turbid  with  many  leucocytes, 
otherwise  negative. 

Diagnosis. — The  senile  coxitis  is  apparent  both  on  physical  exam- 
ination and  from  the  x-ray.  The  apjDarent  shortening  is  due  to  the 
limited  abduction.  AVhether  the  injury  initiated  the  process  or 
brought  to  light  an  already  existing  process  is  unanswered  by  the 
appearance  of  the  other  side.     It  likewise  shows  marked  changes. 


Fig.   227. — Senile  coxitis. 


440 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


We  may  conclude  that  the  injury  served  only  to  emphasize  existing 
conditions — a  factor  of  some  medico-legal  importance  in  some  cases. 
The  absence  of  real  shortening  negates  the  supposition  of  an  im- 
pacted fracture.  The  duration  of  the  articular  process  is  hard  to 
determine  in  such  eases.  Almost  any  old  lady  can  supply  a  history 
of  "chronic  rheumatism"  if  it  will  contribute  to  amity  and  good 
fellowship. 

Treatment. — The  head  of  the  femur  was  removed  under  spinal 
anesthesia.  Considerable  difficulty  was  experienced  because  the  exos- 
tosis about  the  rim  of  the  acetabulum  imprisoned  it.  After  the  head 
was  removed,  the  aeetal)ulum  cartilage  could  be  seen  to  be  eroded 


Fig.  228. — Head  of  femur  from  senile  coxitis. 

and  the  border  studded  with  many  shot-like  excrescences.  Some 
of  the  eroded  areas  in  the  cartilage  were  covered  by  a  recent  fibrinous 
exudate. 

Pathology. — The  head  shows  many  irregularities  and  some  erosions 
(Fig.  228),  though  on  the  whole  the  changes  are  less  marked  than 
in  the  acetabulum. 

After-course. — There  was  but  little  postoperative  reaction,  the  high- 
est pulse  recorded  being  95.  An  extension  of  from  4  to  8  pounds  was 
applied  to  the  leg  after  the  first  few  days.  At  the  end  of  the  second 
week  some  bloody  pus  was  discharged  from  the  lower  end  of  the 
wound.  At  the  time  of  discharge  from  the  hospital  on  the  fifty-sixth 
day  she  had  no  pain,  the  leg  was  2  inches  short,  but  she  was  not  yet 
able  to  bear  her  full  weight  on  the  leg.     It  now  developed  that  she 


DISEASES    OF    THE   LOWER   EXTREMITIES  441 

had  suffered  much  from  the  other  hi]3  and  that  this  was  now  hindering 
much  her  locomotion. 

Comment. — This  ever  present  malady  does  not  kill,  is  but  little  in- 
fluenced by  remedial  or  hygienic  measures,  and  its  surgical  manage- 
ment is  unsatisfactory.  With  spinal  anesthesia  the  operation  has  lost 
its  danger,  but  the  results  are  problematic.  These  patients  are  often 
hypercritical  by  nature  and  anj^thing  short  of  a  normal  joint  will  not 
satisfy.  This  can  not  be  accomplished,  for  there  is  always  shorten- 
ing and  if  the  other  hip  is  likewise  affected,  the  necessary  compensa- 
tory tilting  of  the  pelvis  may  cause  the  unoperated  side  to  give  more 
pain  than  the  operated  one  did  before  treatment  was  begun.  Where 
the  pain  is  very  great,  where  the  x-ray  shows  changes  predominatingly 
confined  to  the  side  complained  of,  and  the  patient  is  intelligent 
enough  to  understand  that  the  surgeon's  powers  are  limited,  operation 
may  be  advised.  When  the  patient  is  loquacious,  hypercritical,  and 
shows  a  bilateral  lesion  by  the  x-ray,  operation  should  be  denied  by  all 
except  young  surgeons  whose  rough  corners  need  polishing  down  as 
much  as  the  joint  surfaces  of  the  patient. 

CASE  6. — An  elevator  attendant  aged  thirty-eight  was  brought  to 
the  hospital  because  of  a  fracture  of  the  hip. 

History.- — On  Nov.  3,  1917,  he  was  struck  on  the  right  hip  and  thigh 
by  a  steel  wheat  conveyor.  He  continued  to  work  for  fifteen  days, 
suffering  nothing  more  than  a  general  soreness.  On  this  day  while  at 
his  work  in  making  a  sudden  turn  he  felt  something  snap  in  his 
right  hip  and  he  fell.  After  this  he  was  able  to  walk  only  "with  the 
aid  of  crutches.  On  June  21,  1918,  nine  months  after  injury  of  the 
right  hip,  while  walking  he  felt  as  if  he  would  fall,  and  in  throwing 
his  weight  back  in  order  to  secure  his  balance  his  left  hip  snapped. 
Since  then  he  has  not  walked.  He  admits  having  a  chancre  eighteen 
years  ago.  For  two  years  he  has  had  no  sexual  desire  whatever. 
Since  then  he  has  had  some  shooting  pains  in  the  legs.  For  a  year  he 
has  had  some  difficulty  in  controlling  his  urine  and  he  has  had  diffi- 
culty in  maintaining  his  balance  while  walking  in  the  dark. 

Examination. — The  patient  is  unable  to  walk,  but  he  can  flex  his 
thighs  on  the  abdomen  and  flex  and  extend  his  legs  on  his  thighs. 
He  has  a  right  foot-drop.  The  patellar  and  Achilles  reflexes  are  ab- 
sent. He  has  an  Argyll  Robertson  pupil  and  there  is  some  diminu- 
tion of  sensation  in  the  feet  and  legs.     There  is  an  abnormal  mobility 


442 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


in  the  hip  joint.  ^Nrovcmciit  is  not  attended  hy  any  pain.  The  x-ray 
shows  a  fracture  in  the  neck  of  each  femur  (Figs.  229  and  230). 
There  is  no  rarefaction  in  tlie  region  of  the  fracture :  on  the  contrary, 
there  seems  to  be  a  condensation  immediately  al)out  the  site  of  frac- 
ture.    Tlie  head  of  tlie  femur  is  much  widened  and  witli  it  tlio  ace- 


Fig.  229. — Spontaneous  fracture  of  the  neck  of  the  left  femur. 


DISEASES    OF    THE    LOWER    EXTREMITIES 


443 


Fig    230. — Spontaneous  fracture   of  the  neck   of  the  right   femur. 


444  CLINICAL   SURGERY   BY    CASE    HISTORIES 

tabulum.  The  laboratory  examinations  were  negative.  Wassermann 
was  not  made. 

Diagnosis. — The  fracture  of  a  hip  from  slight  trauma  always  sug- 
gests first  a  metastatic  neoplasm.  In  a  male  of  this  age  a  kidne}'  tumor 
would  be  a  likely  source.  There  is  nothing  to  indicate  any  aifeetion 
of  tlie  kidney.  The  question  was  brought  up  as  to  whether  or  not 
there  might  not  liave  been  an  impacted  fracture  from  the  injury,  and 
after  fifteen  days  the  impaction  was  mobilized  and  the  patient  inca- 
pacitated. That  a  patient  may  get  about  on  an  impacted  fracture 
and  by  his  efforts  dislodge  it  may  be  admitted.  However,  the  fact 
that  the  second  hip  fractured  without  any  considerable  trauma, 
and  that  the  fractures  were  painless,  makes  such  an  event  unlikely. 
This  conclusion  may  be  reached  even  without  the  consideration  of  the 
classical  signs  of  tabes.  The  presence  of  a  condensation  rather  than 
a  rarefaction  at  the  site  of  fracture  makes  the  diagnosis  of  a  double 
Charcot's  hip  singularly  complete. 

Treatment. — He  was  recommended  to  his  family  physician. 

After-course. — The  patient  has  continued  to  show  a  progression  of 
the  neuropathic  symptonxs  above  outlined. 

Comment. — Within  a  few  months  of  his  primary  injury  he  was  a 
good  subject  for  medico-legal  study  in  determining  the  question  of 
liability.  Even  at  this  time  a  neurologic  examination  would  have  made 
a  correct  diagnosis  possible.  A  tabetic  patient  may,  of  course,  sus- 
tain a  hip  fracture  without  having  a  Charcot  joint.  The  x-ray  may 
then  be  of  prime  importance. 

CASE  7. — A  housewife  ag-ed  fifty-eight  was  found  lying-  on  the 
hospital  steps. 

History. — The  patient  in  descending  the  hospital  steps  slipped  and 
fell  on  her  left  hip.  She  could  iiot  lift  the  left  leg  and  had  to  accept 
assistance. 

Examination. — The  thigh  seemed  in  good  position  save  that  it 
appeared  to  rotate  a  little  outward.  Fearing  a  fracture  and  hoping 
for  an  impacted  one,  the  patient  was  transferred  gently  to  the  x-ray 
table.  The  plate  showed  a  fracture.  There  was  about  half  an  inch 
shortening. 

Diagnosis. — The  appearance  of  the  plate  left  no  doubt  as  to  the 
nature  of  the  malady.  Diagnosis  in  these  cases  can  not  be  made 
before  a  picture  can  be  taken.    Wlien  a  person  of  middle  life  or  be- 


DISEASES    OF    THE   LOWER   EXTRE:\IITIES 


445 


Fig.   231. — Impacted   fracture   of  the    neck   of  the   femur. 


446  CLINICAL   SURGERY    RY    CASK    HISTORIES 

yond  falls  and  is  unable  to  rise,  a  fracture  of  the  neck  of  the  femur 
must  be  assumed  until  proved  otlierwise  by  the  x-ray  (Fig.  231).  If 
there  is  no  impaction,  usually  there  is  extreme  external  rotation  and 
a  shortening  of  several  inches. 

Treatment. — The  leg  was  held  in  position  by  means  of  sand  bags. 
After-course. — A  good  deal  of  pain  in  the  knee  was  complained  of 
for  a  few  days,  but  none  in  the  hip. 

Comment. — This  case  was  imperfectly  impacted  and  should  have 
been  put  up  in  the  Whitman  method.  When  impaction  is  imperfect, 
the  displacement  may  become  gradually  more  marked  and  thus  sur- 
prise the  surgeon  by  a  very  bad  result,  unless  precautionary  meas- 
ures are  taken. 

CASE  8. — A  w^oman  aged  seventy-nine  fell  while  walking-  about 
the  corridor  of  the  hospital. 

History. — The  patient,  an  inmate  of  the  hospital,  fell  to  the 
floor  while  walking.  She  does  not  know  herself  just  how  or  why  she 
fell.  She  was  picked  up,  and  with  the  assistance  of  the  nurses  walked 
back  to  her  own  room,  limping  markedlj^  on  the  right  leg.  She  com- 
plained of  a  severe  pain  in  the  right  hip  joint  and  right  knee. 

Examination. — The  rigli  foot  is  turned  outward  to  about  an  angle 
of  45  degrees  and  there  is  two  inches  of  shortening  in  the  leg.  X-ray 
examination  showed  a  well-impacted  fracture  of  the  right  neck  of 
the  femur.      (Fig.  232.) 

Diagnosis. — The  age  of  the  patient,  the  nature  of  the  injury,  the 
character  of  the  deformity,  even  in  the  absence  of  the  x-ray  plate 
is  sufficient  to  warrant  a  diagnosis  of  impacted  fracture  of  the  neck 
of  the  femur.  The  x-ray  shows  very  well  how  the  crushing  of  the 
bone  brings  about  the  deformity  above  mentioned. 

Treatment. — She  was  placed  in  bed  and  the  leg  surrounded  by  sand 
bags.  She  was  put  upon  a  back  rest  within  a  few  days  after  the 
injury  in  order  to  avoid  hypostatic  pneumonia.  She  suffered  severe 
pain  for  about  a  week  but  after  that  seemed  to  be  but  little  incon- 
venienced by  the  injury. 

After-course. — After  four  weeks  she  was  lifted  out  into  a  chair 
and  in  an  additional  week  or  two  was  able  to  walk  about  her  room. 

She  apparently  has  good  union  with  about  2  inches  of  shortening. 

Comment. — Spontaneous  impaction  is  the  most  favorable  outcome 


DISEASES    OF    THE    LOWER   EXTREMITIES  447 

in  fractures  of  the  neck  of  the  femur.  In  conveying  the  patient  every 
effort  should  be  made  to  preserve  the  relations.  It  is  particularly 
desirable  in  these  aged  patients  that  they  be  placed  in  a  sitting  posi- 
tion as  early  as  possible.  Despite  every  precaution,  many  of  them 
succumb  to  hypostatic  pneumonia. 


Fig.  232. — Impacted  fracture  of  the  neck  of  femur. 


448  CLINICAL   SURGERY   BY    CASE    HISTORIES 

CASE  9. — A  traveling-  man  aged  forty-eight  came  to  the  hospital 
because  of  pain  in  his  leg-. 

History. — In  1893  this  patient  had  an  attack  of  lumbago,  lasting 
two  weeks.  In  1906  he  was  confined  to  bed  for  two  weeks  with  pain 
in  the  knee  and  leg.  No  cause  for  the  trouble  could  be  given.  The 
leg  would  draw  up.  Morphine  was  used  for  the  pain  for  a  week  at 
this  time.  There  was  no  swelling  of  the  joints  at  any  time.  Sixteen 
months  before  entering  the  hospital,  in  May,  1915,  he  was  thrown 
forward  over  three  seats  in  a  railroad  wreck  in  California.  The 
next  day  he  was  able  to  walk  twelve  blocks  and  had  no  pain  except 
in  the  head.  On  the  day  following,  however,  he  had  pain  in  the  back 
and  left  leg,  but  was  still  able  to  walk.  This  condition  grew  worse. 
He  was  treated  by  an  osteopath  for  five  weeks.  During  this  time  he 
got  about  with  the  aid  of  a  clutch  and  cane  and  continued  to  use 
them  for  six  months.  Then  for  three  months  he  was  feeling  fine  and 
did  not  use  crutches.  One  day  he  slipped  and  fell  down  stairs.  He 
went  to  bed  for  a  day,  had  pain  in  the  back  and  hip.  He  was  in  bed 
at  home  for  two  weeks  with  severe  pain  in  the  right  hip  and  back. 
The  pain  was  worse  at  night.  Twice  a  doctor  had  to  give  ether  and 
manipulate  tlir  liip.  The  pain  continued  just  the  same  for  six  months, 
up  to  the  time  he  entered  the  hospital.  It  was  ver^^  severe  at  times 
and  would  frequently  run  down  the  thigh  and  leg.  He  was  able  to 
walk  only  witli  the  aid  of  crutch  and  cane. 

Examination. — The  physical  examination  of  the  chest  and  abdo- 
men was  negative.  Lifting  the  right  leg  or  flexing  the  thigh  on  the 
abdomen  caused  great  pain  in  the  region  of  the  hip.  There  was  ten- 
derness on  pressure  over  the  sciatic  nerve.  Koentgenograms  of  the 
hip  showed  all  structures  normal,  and  the  head  of  the  femur  in  the 
acetabulum.  There  was  a  marked  curvature  of  the  spine  away  from 
the  affected  side.     Urine  negative ;  temperature  normal,  pulse  70. 

Diagnosis. — The  dominating  feature  of  this  case  is  pain  in  the  lum- 
bar region  and  back  of  the  hip  extending  do"\ATi  the  leg.  The  history 
is  complicated  by  two  distinct  injuries  of  indefinite  character.  The 
main  point,  however,  is  the  fact  that  he  had  lumbago  in  1893  and  was 
confined  to  bed  with  a  pain  extending  down  the  leg  in  1906.  These 
complaints  antedated  both  injuries.  Neither  injury  was  of  a  definite 
character  and  were  not  attended  hx  an  immediate  disturbance  of  the 
motor  function.  He  now  presents  pain  and  tenderness  along  the  sci- 
atic nerve.     There  is  pain  on  flexion,  but  none  on  rotation,  indicat- 


DISEASES   OF    I'HE   LOWER   EXTREMITIES  449 

ing  freedom  in  tlie  hip  joint.     The   diagnosis,  therefore,  must  be 
sciatica. 

Treatment. — The  patient  was  put  to  bed  and  the  sciatic  nerve  in- 
jected with  a  one  per  cent  solution  of  quinine  urea  hydrochloride.  This 
treatment  was  repeated  in  one  week.  A  few  daj^s  after  the  second 
injection,  the  patient  was  allowed  to  go  home  with  instructions  to 
return  at  intervals  for  further  treatment.  He  was  very  much  im- 
proved when  he  left  the  hospital,  but  still  had  some  pain.  After  four 
injections  the  pain  was  entirely  gone.  The  patient  could  walk  without 
a  limp  and  resumed  his  work. 

After-course. — The  j^atient  has  been  free  from  pain  for  two  years. 

Comment. — The  relief  from  pain  \>j  the  injection  of  the  nerve  is 
strong  corroborative  evidence  of  the  correctness  of  the  diagnosis. 
Had  there  been  any  skeletal  injury,  relief  would  not  have  followed 
these  measures.  Once  a  person  has  had  sciatica,  injuries  of  many 
kinds  may  cause  a  recrudescence  of  the  symptonLS. 

In  the  presence  of  bony  changes  this  treatment  obviously  can  not 
be  successful  in  removing  the  bony  changes.  Even  in  those  cases, 
however,  it  does  relieve  the  pain  in  the  sciatica.  It  is  a  symptomatic 
cure.  An  acute  arthritis  apparently  may  set  up  a  nerve  pain  which 
does  not  subside  when  the  joint  trouble  disappears.  Conversely, 
the  nerve  pain  may  subside  when  a  joint  inflammation  proceeds  to 
complete  ankylosis. 

CASE  10. — A  newspaper  man  aged  twenty-five  came  because  of 
pain  in  his  hip. 

History. — His  health  has  always  been  good  save  for  an  attack  of 
inflammatory  rheumatism  at  the  age  of  ten.  Four  months  ago  he 
noticed  that  the  left  hip  joint  felt  as  if  it  did  not  work  smoothly. 
One  day  he  stumbled  and  fell,  after  which  he  was  laid  up  in  bed 
several  days  with  pain  in  the  hip  and  soreness  in  the  groin.  Grad- 
ually the  hip  became  better,  but  it  was  several  days  before  he  could 
use  it  without  considerable  pain.  Ten  days  ago  he  slipped  while 
walking  along  the  sidewalk  and  hurt  the  hip  again.  He  now  limps 
and  has  pain  on  walking.  At  flrst  the  pain  was  in  the  hip  joint,  and 
in  the  groin.  Now  when  lying  down  the  whole  leg  aches,  but  most 
in  the  calf.  He  has  never  noticed  any  swelling  or  redness  about 
the  hip. 

Examination. — Movements  of  the  hip  joint  are  free.  He  can  flex 
the  thigh  on  the  abdomen  without  pain.     There  is  some  tenderness 


450 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


on  pressure  in  the  left  groin.  There  is  no  tenderness  over  the  sciatic 
nerve  at  any  point.  X-ray  of  the  pelvis  shows  the  hip  joint  normal 
but  absence  of  shadow  of  the  left  ramus  of  the  pubis  (Fig.  233). 
The  right  shows  normally. 

Diagnosis. — The  absence  of  the  ramus  of  the  pubes  must  be  due 
to  a  neoplastic   growth.     Tuberculosis   does  not   affect   the   bone   so 


Fig.   233. — Sarcoma   of  jiubic   bone. 

far  away  from  a  joint  surface  and  does  not  destroy  it  so  completely. 
The  only  lesion  capable  of  producing  so  extensive  a  loss  of  bone 
substance  is  sarcoma. 

Treatment. — The  case  was  considered  inoperable  on  account  of  the 
location  of  the  tumor.  X-ray  treatment  was  advised  and  given,  but 
without  result. 


DISEASES    OF    THE   LOWER    EXTREMITIES 


451 


After-course. — The  srmptcms  increased  in  severity  in  spite  of  vig- 
orous x-ray  treatment  and  soon  a  mass  appeared  in  the  groin.  When 
examined  six  months  later  this  mass  had  grown  to  the  size  of  a  small 
fist.     The  x-ray  at  this  time  showed  extensive  involvement  of  the  hip 


Fig.  234. — Sarcoma  involving  the  pubis,  ischium  and  head  of  the  femur. 

joint,  head  of  the  femur  and  the  ileum  (Fig.  234).    The  patient  died 
nine  months  after  the  first  examination. 

Comment. — Until  the  x-ray  was  taken,  the  suspicion  was  directed 
against  an  infiammatory  atfection  of  the  hip  joint.  The  involvement 
of  the  pubic  bone  was  a  surprise. 


452  CLINICAL   SURGERy   BY    CASE    HISTORIES 

DISEASES  OF  THE  THIGH 

Diseases  of  the  thioli  Avhicli  require  diagnostic  judgment  are  the 
tumors  of  the  adductor  muscles  and  those  of  the  sciatic  nerve.  The 
badly  healed  fractures  and  the  late  result  of  osteomyelitis  tax  the 
mechanical  ingenuity  rather  than  the  scientific  attainments  of  the 
surgeon. 

CASE  1. — A  housewife  of  forty-eight  came  to  the  hospital  because 
of  the  development  of  a  tumor  in  the  site  of  an  old  scar. 

Ilistorij. — "When  eighteen  years  old  the  patient  received  a  severe 
burn  of  the  outer  surface  of  the  right  thigh.  After  many  months 
it  healed  over,  leaving  a  large  scar.  Some  months  ago  a  small  nodule 
began  to  develop  in  the  center  of  this  scar.  As  it  grew  the  surface 
covering  it  became  thinned  and  bled  at  times.  No  real  pain  devel- 
oped, but  she  is  conscious  of  a  discomfort. 

Examination. — Beginning  just  below  the  great  trochanter  is  a  large 
scar  (Fig.  235).  It  is  covered  with  a  dry  corrugated  epidermis.  Near 
the  center  of  this  are  two  nodules,  each  larger  than  a  walnut.  The 
covering  is  deep  red.  The  lower  one  has  become  eroded  and  bleeding 
occurs  when  the  scab  is  removed.  The  masses  are  hard  and  seem  to  be 
continuous  with  the  surrounding  skin.  It  can  be  caused  readily  to 
bleed. 

Diagnosis. — A  tumorous  mass  developing  in  an  old  scar  is  most 
sure  to  be  epithelial  in  character.  The  tendency  of  these  tumors  to 
become  eroded  supports  this  general  rule. 

Treatment. — The  large  scar  together  with  the  tumors  was  excised. 
The  incision  extended  to  the  fascia  lata.  Because  of  the  depth  of  this 
cavity  immediate  grafting  could  not  be  practiced.  The  wound  was 
narrowed  as  much  as  possible  and  the  appearance  of  granulations 
was  awaited  before  grafting  was  attempted.  A  part  of  the  wound 
w^as  treated  with  scarlet  R  while  the  remainder  was  dressed  with 
plain  gauze.  No  difference  in  the  rate  of  healing  of  the  areas  thus 
differently  treated  could  be  noticed.  After  several  months  complete 
epidermization  was  obtained. 

After-course. — Recovery  was  permanent. 

Comment. — Because  of  the  poor  nutrition  of  the  sear  ahout  the 
tumor  masses  it  was  deemed  best  to  excise  it  in  its  entirety.  Besides, 
since  one  tumor  developed  in  the  scar,  others  might  have  developed 
in  other  parts  of  it. 


DISEASES   OF    THE   LOWER   EXTREMITIES 


453 


Fig.    235. — Carcinoma  developing  in  an  old  burn   scar   of  the  thigh. 

CASE  2. — A  young-  married  woman  aged  twenty-three  came  be- 
cause of  a  tumor  on  her  thigh. 

History. — As  long  as  she  can  remember  she  has  had  a  tumor  half 
an  inch  across  just  above  her  knee.  Two  months  ago  she  began  to 
have  some  uncomfortable  feelings  in  it  and  when  she  examined  it 
she  noticed  a  small  tumor  growing  beside  the  larger  one.     She  does 


454  CLINICAL   SURGERY   BY    CASE    HISTORIES 

not  remember  having  injured  the  tumor  at  any  time,  but  thinks  the 
jumping  of  her  baby  on  her  lap  may  have  irritated  it.  At  any  rate, 
it  was  during  one  of  his  performances  that  she  first  noticed  the  irri- 
tation that  led  to  an  investigation  and  the  discovery  of  the  accessory 
tumor. 

Examination. — On  the  anterior  inner  surface  of  the  thigh  is  a  tu- 
mor 1.5  cm.  in  diameter.  It  is  covered  by  a  thinned  corrugated  skin 
which  is  closely  adherent  to  the  tumor.  The  base  of  the  tumor  is 
somewhat  constricted.  Just  lateral  to  the  main  tumor  mass  is  a 
small  smooth  nodule  the  size  of  a  hazelnut.     This  tumor  is  redder  in 


Fig.  j36.  — ^re!anoljIastcma   of  the  thigli. 

color  and  is  covered  with  a  smooth,  tense  skin.  The  whole  moves 
freely  with  the  skin.  There  are  no  glands  palpable  in  the  inguinal 
region.     (Fig.  236.) 

Diagnosis. — The  original  tumor  at  first  glance  suggests  a  flat  bos- 
selated  papilloma  which  usually  remain  unchanged  throughout 
life.  Closer  inspection,  however,  shows  that  instead  of  having  a 
thickened  epithelial  covering  it  is  in  fact  much  thinned,  and  fine  blood 
vessels  can  be  seen  in  it.  This  indicates  that  it  belongs  to  the  melano- 
blastoma  or  fibrosarcoma  group.  The  sudden  appearance  of  the 
small  nodule  is  evidence  not  only  of  potential  but  actual  active  ma- 
lignanc.y.  There  is  no  evidence  of  proliferation  in  the  mother  tumor. 
The  free  mobilitv  of  the  skin  together  with  the  tumor  and  the  absence 


DISEASES    OF    THE    LOWER   EXTREMITIES  455 

of  glandular  involvement  makes  it  hopeful  that  the  process  is  still 
localized. 

Treatment. — A  wide  margin  was  excised  with  the  tumor  down  to 
the  fascia  lata. 

PatJiology. — The  original  tumor  is  made  up  of  interlacing  fibro- 
cellular  tissue,  while  the  secondary  tumor  shows  masses  of  round 
and  ovoid  cells  arranged  in  pseudoalveoli  resembling  that  often  seen 
in  well-developed  melanoblastomic  tumors  of  the  sole  of  the  foot. 

After-course. — Recovery  has  been  permanent. 

Comment. — Any  congenital  tumor  may  become  a  source  of  a  malig- 
nant tumor.  Solitary  tumors,  particularly  if  pigmented,  near  the 
groin  or  axilla  should  be  removed.  Those  elsewhere  should  be  re- 
moved if  they  show  a  disposition  to  grow, 

CASE  3. — A  married  woman  of  twenty-four  came  to  the  hospital 
because  of  a  tumor  of  the  thigh. 

History. — Two  years  ago  she  noticed  a  tumor  the  size  of  a  bean  on 
the  inner  side  of  the  calf  midway  betAveen  the  ankle  and  knee.  It 
had  a  red  surface.  Some  months  later  she  developed  a  dull  pain 
above  the  knee  on  the  inner  side  of  the  thigh.  A  surgeon  discovered 
a  tumor  in  this  region  and  removed  it  together  with  the  little  tumor 
below  the  knee.  For  the  past  six  months  a  tumor  has  been  developing 
along  the  thigh  above  where  the  tumor  was  originally  removed.  Her 
general  health  has  always  been  good.  She  has  been  married  five 
years,  has  two  living  children,  one  dead  of  pneumonia,  and  one  pre- 
mature. 

Examination. — There  is  a  soft  scar  half  an  inch  long  a  handbreadth 
below  the  head  of  the  tibia.  A  like  distance  above  the  internal  con- 
dyle of  the  femur  is  a  scar  two  inches  long.  From  this  scar  to  above 
Poupart's  ligament  is  an  irregular  oblong  tumor  about  2x5  inches 
(Fig.  237).    It  can  be  moved  laterally,  but  not  longitudinally. 

Diagnosis. — ^The  history  of  the  small  tumor  with  the  red  top  below 
the  knee,  with  the  tumor  above  the  knee,  now  recurrent,  stamps  the 
disease  as  a  melanoblastoma.  The  diagnosis  is  concerned  chiefly 
with  the  operability  of  the  recurrent  tumor.  The  absence  of  dilated 
veins  and  its  rather  free  lateral  mobility  makes  it  likely  that  the 
growth  is  technically  operable. 

Treatment. — The  tumor  was  exposed  at  its  upper  pole  which  was 
found  to  extend  2  inches  above  Poupart's  ligament.     The  external 


456 


CIJXICAL   SURGERY   BY    CASE    HISTORIES 


Fig.   237. — Recurrent   melanoblastoma    cf  the   thi 


DISEASES   OF    THE   LOWER   EXTRE:\IITIES  457 

iliac  A'essels  were  exposed.  The  portion  of  Poupart's  ligament  to 
which  the  tumor  was  attached  was  removed.  The  long  saphenous  vein 
was  incorporated  in  the  tumor  and  was  resected.  Numerous  small 
veins  ran  from  the  tumor  to  the  femoral  vein  in  the  region  below  the 
long  saphenous  opening.  At  one  point  the  tumor  was  attached  to 
the  femoral  vein  and  a  portion  of  the  vein  wall  had  to  be  sacrificed 
after  sewing  it  through  and  through  with  silk.  The  vein  was  exposed 
to  Hunter's  canal. 

Pathology. — The  tumor  when  split  longitudinally  showed  white 
glistening  bands  with  pinker  areas  between.  The  slides  showed 
alternating  fibrous  and  spindle-celled  areas. 

After-course. — The  wound  healed  readily.  She  gave  birth  to  her 
fifth  child  six  months  after  the  operation.  All  went  well  until  a 
year  and  a  half  after  the  operation,  when  she  noticed  a  tumor  below 
the  knee  in  the  region  of  the  scar  resulting  from  the  removal  of  the 
small  primary  tumor.  This  grew  rapidly  and  in  six  months  was  the 
size  of  two  fists  and  caused  great  pain.  This  was  removed  with  diffi- 
culty because  it  was  intimately  attached  to  the  peritoneum  of  the 
tibia.  Other  tumors  as  large  as  a  walnut  were  located  in  Hunter's 
canal  and  several  larger  ones  in  the  retroperitoneal  space.  These 
last  were  not  molested.  The  pain  ceased  after  the  removal  of  the 
calf  tumor.  A  year  after  this  last  operation  her  physician  reports 
having  just  delivered  her  of  the  sixth  child  and  that  the  retroperi- 
toneal tumors  are  slowly  enlarging,  but  that  the  patient's  general 
health  remains  good. 

Comment. — It  is  not  likely  that  any  of  these  operations  have  con- 
tributed any  toward  prolonging  the  life  of  the  patient.  The  removal 
of  the  tumors  of  the  calf  relieved  her  of  severe  pain  and  in  that  finds 
a  measure  of  justification.  The  slow,  relentless  progress  is  typical 
of  the  disease. 

CASE  4. — A  stockman  ag'ed  thirty-three  presented  himself  be- 
cause of  pain  and  swelling  in  the  inner  side  of  the  thigh. 

History. — He  has  always  been  well.  Three  mouths  ago  he  was 
kicked  on  the  inside  of  the  leg  above  the  knee  while  ''hog  tying"  a 
steer.  He  has  never  been  obliged  to  quit  work,  but  the  area  has  much 
interfered  with  riding  horseback. 

Examination. — Beginning  a  handbreadth  above  the  inner  condyle 
is  a  hard  spindleform  swelling  which  extends  upward  half  the  length 


458 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


of  the  thigh.  It  is  dense,  iiimiovable,  aud  but  slightly  tender  to 
pressure.  Pain  is  caused  by  attempted  abduction  against  resistance. 
The  x-ray  shows  a  deep  shadow  parallel  with  the  shaft  of  the  femur. 
It  is  less  dense  than  the  femur  but  yet  has  the  parallel  lamellae  of 
bone. 

Dwgnosis. — The  history  of  trauma,  the  gradual  development  of 
a  dense  swelling  parallel  with  the  bone  and  attached  to  it  (Fig.  238) 
always  suggests  an  ossifying  myositis.  The  x-ray  which  shows  the 
arrangement  of  the  bone  fibers  parallel  with  the  adjoining  bone 
proves  the  diagnosis.  These  conditions  are  sometimes  confused  with 
osteosarcoma.     In  this  latter  condition  the  bone  spicules  radiate  like 


Fig.   238. — Myositis  ossificans   traumatica. 


a  fern  bush  from  the  shaft  of  the  bone  from  which  they  spring 
(Fig.  239). 

Treatment. — Xone. 

After-course. — The  soreness  lessened  aud  tlie  mass  became  reduced 
in  size. 

Comment. — The  nature  of  the  process  which  is  able  to  produce  bone 
is  not  understood.  When  attached  to  the  bone,  these  processes  might 
be  ascribed  to  the  extension  outward  of  periosteal  osteogenic  cells. 
When  not  so  attached,  the  migration  of  these  cells  or  the  metamorpho- 
sis of  other  cells  must  be  hypothecated.  The  point  most  worth  know- 
ing, often  overlooked,  is  that  these  masses  notwithstanding  that  they 
seem  well  fonned  bone  under  the  x-ray.  are  capable  of  marked  re- 
duction in  the  due  process  of  time.     It  is  seldom  that  operation  is 


DISEASES    OF    THE   LOWER   EXTREMITIES  459 

indicated  unless  the  new  formed  bone  is  so  located  that  it  impinges 
on  a  neighboring  joint  when  the  limb  is  flexed. 


Fig.    239. — Museum   specimen   of   a   bone    frnm    a    case   of   osteosarcoma. 

CASE  5. — I  was  called  to  see  a  retired  business  man  aged  eighty- 
two  because  of  pain  in  his  foot  and  a  tumor  in  his  thigh. 

History. — A  month  ago  the  patient  began  to  have  severe  pains  in 
his  right  foot.     It  soon  was  noticed  that  the  toes  were  cold.     Snbse- 


460 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


quently  the  toes  blackened  and  tlie  skin  -was  mottled  above  the  ankles. 
Simultaneously  with  this  a  sausage-shaped  mass  appeared  in  the  lower 
part  of  the  inner  surface  of  the  thiiili.  He  has  complained  bitterly 
of  the  pain  and  has  had  to  have  morphine  for  the  relief  of  pain, 
lie  has  been  resth^ss  in  the  induced  sleep  and  at  times  seems  irrational 
during^  his  waking  moments. 


Fig.  240. — Aneurysm   of  the  femoral  artery. 

Examinafioit. — The  patient  is  an  emaciated,  decrepit  old  man  whose 
face  bears  evidence  of  acute  pain.  His  radial  arteries  are  hard  and 
beaded,  his  apex  beat  is  diffused.  There  is  a  sausage-shaped  mass 
extending  along  Hunter's  canal  reaching  from  the  middle  of  the  pop- 
liteal space  to  the  lower  termination  of  Scarpa's  triangle  (Fig.  240), 
The  femoral  artery  pulsates  vigorously  but  below  the  tumor  mass 
no  pulsation  can  be  found.     The  tumor  mass  is  2  to  3  cm.  in  diam- 


DISEASES    OP    THE   LOWER   EXTREMITIES  461 

eter,  but  sliglitly  tortuous  at  its  lower  end  and  dense  throughout, 
though  it  is  somewhat  expansile.  The  foot  is  black  as  high  as  the 
midtarsal  line  and  mottled  blue-black  nearly  as  high  as  the  knee. 
The  affected  parts  are  dry  and  cold.  The  artery  in  Scarpa's  triangle 
is  hard  but  no  placiues  can  be  palpated. 

Diagnosis. — A  glance  sufficed  to  characterize  the  condition  as  a 
senile  gangrene.  The  sausage-shaped  tumor  occupying  Hunter's 
canal  must  needs  be  a  thrombosed  and  dilated  vessel.  Its  density 
indicates  a  clot  and  its  expansibility  still  the  presence  of  some  fluid 
blood.  The  question  of  operability  hinges  on  the  state  of  the  artery  in 
Scarpa's  triangle.  While  hard  it  still  seems  compressible.  The  de- 
termination of  the  patient's  general  state  as  related  to  the  condition 
of  the  leg  was  desirable  in  order  to  estimate  the  value  of  ajnputa- 
tion.  It  was  believed  that  an  amputation  above  the  aneurysm  would 
relieve  the  patient  of  his  pain.  His  mental  aberration  was  regarded 
as  likely  due  to  cerebral  changes  because  he  had  had  an  attack  which 
suggested  a  cerebral  hemorrhage.  It  was  hoped,  however,  that  ab- 
sorption from  the  leg  might  play  a  part. 

Treatment. — Two  grains  of  novocain  sterilized  for  three  minutes  in 
3  c.c.  of  boiled  distilled  water  were  injected  into  the  spinal  cavity  be- 
tween the  fourth  and  fifth  lumbar  vertebra.  The  femoral  artery  was 
cut  down  upon  at  the  lower  angle  of  Scarpa's  triangle  and  ligated 
with  chromic  catgut  and  linen.  The  spindleform  mass  was  dissected 
downwards  from  its  bed  until  the  junction  of  the  lower  and  middle 
thirds  of  the  thigh  was  reached.  The  soft  parts  were  then  divided, 
by  a  circular  incision  and  retracted  to  permit  severing  the  bone 
at  its  middle  point. 

Pathology. — The  popliteal  vein  was  thrombosed  as  was  the  poplit- 
eal artery.  The  spindleform  mass  was  hardened  before  sectioning. 
It  was  found  to  be  occupied  by  a  blood  clot  (Fig.  241). 

After-course. — Recovery  from  the  amputation  was  uneventful.  He 
continued  to  complain  of  pain,  however,  and  had  to  have  codeine. 
His  mental  state  was  perturbed  before  the  operation  and  continued 
so  until  he  died  of  progressive  weakness  six  weeks  after  the  operation. 

Comment. — The  hope  that  the  removal  of  the  leg  would  at  least 
produce  a  relief  from  pain  was  not  realized.  His  mental  state  was 
believed  to  be  due  to  changes  in  the  central  arteries  and  no  improve- 
ment was  looked  for.  He  had  had  morphine  before  the  operation 
and  it  is  not  possible  to  know  to  what  degree  his  complaint  subse- 


462 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


Fig.   241. — Cross   section   of   the   aneurysm. 


DISEASES    OF    THE    LOWER    EXTREMITIES  463 

qnent  to  the  operation  was  due  to  the  contmuance  of  the  pain  and 
how  much  to  a  desire  for  the  continuance  of  the  drug.  At  least  he 
had  his  way  and  the  drug  was  continued.  The  patient  was  in  no  way 
benefited  by  the  operation  and  his  life  likely  was  not  prolonged.  It 
did  prove  the  one  point  of  technical  feasibility.  It  was  a  good 
operation,  but  poor  surgery. 

CASE  6. — A  farmer  aged  forty-eight  came  to  the  hospital  because 
of  pain  in  the  stump  of  a  thigh. 

History. — The  patient  had  a  midthigh  amputation  twelve  years 
ago  because  of  a  compound  fracture.  The  stump  was  painless  for  a 
year  follo^Wng  amputation,  but  at  the  end  of  this  time  he  began  to 
have  severe  pains  in  the  back  part  of  the  thigh.  It  was  not  constant, 
and  for  long  periods  he  was  entirely  free.  He  has  always  imbibed 
freely  of  alcohol  and  recently  he  has  drunk  to  excess.  He  has  some 
pain  in  his  other  leg  and  occasional  pains  in  his  arms. 

Examination. — The  stump  presents  a  puckered  mass  of  scar  at 
the  lower  and  posterior  extremity  of  the  thigh  bone.  It  is  not  sensi- 
tive to  touch.  There  is  some  tenderness  along  the  course  of  the 
sciatic  nerve  and  in  the  lumbar  region.  There  is  some  tenderness 
over  the  sciatic  nerve  in  the  other  leg. 

Diagnosis. — The  history  and  character  of  the  sear  suggest  that 
the  termination  of  the  nerve  is  embedded  in  the  scar,  possibly  with 
a  hypertrophy  of  the  nerve  substance  itself,  the  so-called  amputation 
neuroma.  The  fact  that  he  has  been  a  pronounced  alcoholic  and  that 
other  nerves  in  the  body  are  sensitive  to  touch  and  spontaneously 
painful  suggests  the  possibility  of  an  alcoholic  neuritis.  The  fact 
that  he  had  pains  in  the  stump  many  years  before  he  had  pains  in 
the  other  extremities  makes  it  likely  that  the  nerve  in  the  stump  is 
suffering  mechanical  injury. 

Treatment. — An  incision  was  made  over  the  course  of  the  sciatic 
nerve  above  the  scar.  The  nerve  was  isolated  and  severed  in  such  a 
manner  that  a  V-shaped  notch  remained  in  the  proximal  end.  These 
limbs  were  united  and  the  nerve  allowed  to  retract  within  the  wound. 
The  scar  tissue  was  then  freed  to  the  end  of  the  bone.  This  then  was 
sawed  off  two  inches  from  its  extremity.  In  this  way  the  tip  of  the 
bone  and  the  attached  soft  parts  were  removed.  The  soft  tissues 
were  then  closed  over  the  end  of  the  bone  in  layers. 

Pathology. — The  tip  of  the  nerve  which  was  embedded  in  the  scar 


464  CLINICAL   SURGERY   BY   CASE   HISTORIES 

tissue  was  as  large  as  a  hickory  nut  and  gradually  thinned  until  the 
normal  size  of  the  nerve  was  reached  three  inches  from  its  extremity. 
On  section  the  clubbed  end  of  the  nerve  proved  to  be  made  up  of 
a  dense  tissue  which  consisted  of  masses  of  medullated  nerve  fibers 
intermixed  with  much  dense  fibrous  tissue. 

After-course. — There  was  little  immediate  improvement,  l)\it  he 
gradually  ])ecame  free  from  pain  botli  in  the  member  operated  on  aud 
the  others  as  well.    The  patient  has  been  free  from  pain  eight  years. 

Com))ient. — If  the  scar  tissue  in  such  cases  is  separated  from  the 
bone  and  resected  in  the  close  proximitj'  of  the  scar  mass  they  are 
prone  to  reform.  If  the  incision  is  made  in  unaffected  tissue,  this 
is  less  likely  to  take  place.  By  excising  the  nerve  several  inches  from 
the  end,  there  is  little  likelihood  of  a  recurrence.  These  precautions 
are  more  important  if  reoperation  is  done  witliin  a  year  or  two  of 
the  primary  amputation.  In  this  case  the  pains  no  doubt  were  ag- 
gravated by  the  free  imbi])ition  of  alcoholics. 

CASE  7. — A  hardware  dealer  aged  fifty-eight  was  brought  to  the 
hospital  because  of  a  fractured  femur. 

History. — The  patient's  general  health  has  always  been  good  until 
this  illness.  His  wife  has  had  no  miscarriages.  He  has  had  some 
backache  for  fifteen  years.  About  a  year  ago  he  was  kicked  off 
the  sidewalk.  He  does  not  know  which  part  of  the  body  struck 
the  ground,  but  his  right  thigh  hurt  for  about  ten  days  afterward. 
Some  time  later  he  slipped  and  fell  on  the  ice  and  again  hurt  the 
right  hip.  He  was  soon  able  to  be  up  and  around,  however.  Since 
that  time  he  noted  that  any  misstep  caused  pain.  Last  August 
while  in  Colorado  he  noticed  pains  in  various  parts  of  the  body, 
particularly  in  the  back,  arm,  legs,  and  lower  chest.  He  came  back 
from  Colorado  five  months  ago  and  has  been  hardly  able  to  get 
around  since  that  time.  He  tried  Christian  Science  three  weeks,  but 
quit  this  treatment  because  he  knew  he  did  have  pain  despite  the 
contention  of  the  healer  that  he  had  none.  Six  weeks  ago  the  right 
thigh  broke  while  turning  in  bed.  Since  that  time  pain  has  been 
very  severe.  His  weight  has  been  decreased  from  240  to  180 
pounds.  After  the  thigh  Avas  fractured,  the  pain  in  the  other  parts 
of  the  body  left  for  a  period  of  several  weeks.  It  has  now  begun 
again  in  both  sides  of  the  chest,  both  thighs  and  left  arm.  He  had 
his  teeth  removed  three  weeks  ago,  because  it  was  believed  this 


DISEASES    OF    THE    LOWER    EXTREMITIES 


465 


Fig.   242. — Multiple  myeloma  of  the  humicrus. 


466  CLINICAL   SURGERY   BY    CASE    HISTORIES 

trouble  -was  due  to  oral  sepsis.  His  appetite  is  poor,  lie  sleeps  badh^ 
and  he  has  a  constant  feeling  of  exhaustion. 

Examination. — The  patient  gives  the  general  impression  of  a  once 
powerful  man  who  has  suffered  much  pain.  His  tissues  are  soft  and 
the  skin  flabby  and  indefinitely  cachectic.  No  tumor  is  discoverable. 
He  is  tender  over  all  long  bones,  particularly  the  ribs  and  left  hu- 
merus. The  urine  is  1.022  sp.  gr.,  clear,  of  dark  straw  color.  It 
gives  a  heavy  milky  turbidity  when  heated  to  60  degrees.  This 
turbidity  nearly  entirely  disappears  when  the  boiling  point  is  ap- 
proached. "When  a  drop  of  nitric  acid  was  added  to  2  c.c.  of  the 
urine,  this  turbidity  disappeared  on  shaking,  but  remained  perma- 
nently when  ten  more  drops  of  the  acid  were  added.  The  x-ray  shows 
a  mottling  of  the  long  bones,  particularly  the  left  humerus  (Fig. 
242).  The  region  of  the  spontaneous  fracture  shows  extensive  thin- 
ning of  bone  because  of  absorption  from  the  medullary  side.  There 
seems  to  be  an  effort  at  healing  from  the  surrounding  peritoneal  sur- 
face. 

Diagnosis. — Spontaneous  fracture  of  a  long  bone  in  a  previously 
robust  individual  indicates  an  intramedullary  new  growth.  The 
common  sources  of  such  tumors  are  hypernephroma  in  the  male  and 
breast  carcinoma  in  the  female,  and  occasionally  the  thyroid  in 
either  sex.  Inspection  failed  to  reveal  a  new  growth.  The  urine 
showed  nothing  indicative  of  a  neoplastic  process.  The  thyroid 
was  negative.  The  urine  responded  to  the  tests  for  Bence-Jones 
albumin.  The  presence  of  Bence-Jones  albumin  is  in  itself  pathog- 
nomonic for  multiple  myeloma,  though  it  may  be  remembered  that 
this  substance  has  been  found  in  the  urine  of  patients  suffering  from 
myxedema  and  lymphatic  leukemia.  There  was  no  indication  of 
the  presence  of  these  maladies.  The  x-ray  examination  gives  val- 
uable confirmatory  evidence  and  serves  as  a  differentiation  from 
metastasis  of  other  tumors.  The  multiplicity  of  lesions  seen  in  this 
disease  is  not  encountered  in  metastatic  tumors. 

Treatment. — Arsenic  was  given  on  general  principles  and  anodynes 
and  hypnotics  to  secure  comfort. 

After-course. — The  patient  returned  home  and  died  of  progressive 
exhaustion  five  weeks  later.  AVhile  in  the  hospital  for  examination, 
he  passed  a  slight  amount  of  blood  in  the  stool  and  likewise  coughed 
up  some.     He  was  slightly  delirious  at  times. 

Comment. — It  is  ordinarilv  considered  that  the  diagnosis  of  this 


DISEASES   OF    THE   LOWER   EXTREMITIES  467 

disease  is  a  wholly  simple  matter.  The  chief  difficulty  is  that  early 
in  the  disease  the  Bence-Jones  albumin  is  intermittingiy  present,  and 
misleading  conclusions  are  apt  to  be  reached  if  the  urine  is  examined 
during  the  free  interval.  The  multiplicity  of  pains  is  suggestive  and 
may  precede  the  appearance  of  the  specific  albumin.  At  this  time 
a  careful  examination  of  the  blood  may  be  required  to  reach  a  differ- 
entiation, and  it  must  be  remembered  that  the  blood  picture  in  perni- 
cious anemia  may  be  elusive  and  inconstant.  In  fact  the  presence  of 
erythroblastic  cells  in  multiple  myeloma  and  the  nucleated  reds  in 
pernicious  anemia  may  indicate  that  the  diseases  are  in  a  degree  re- 
lated. The  emaciation  in  myeloma,  as  well  as  the  sense  of  exhaustion, 
is  probably  due  to  toxemia  and  the  pains  to  pressure  absorption.  At 
least  the  pains  complained  of  remind  one  of  those  described  for  chron- 
ic abscesses  in  bone.  This  view  is  substantiated  by  the  fact  that 
when  the  absorption  is  extreme,  pain  grows  less.  I  once  saw  a  man 
who  had  so  much  thinning  of  bone  that  he  had  countless  fractures 
of  the  long  bones,  and  the  ribs  were  so  honey-combed  that  even  a 
moderately  gentle  palpation  would  produce  a  fracture.  He  com- 
plained only  of  complete  exhaustion. 

CASE  8. — A  school  girl  aged  twelve  was  brought  to  the  hospital 
because  of  a  badly  united  fracture  of  the  femur. 

History. — Five  months  ago  while  running  she  made  a  quick  turn 
which  caused  her  to  fall  and  break  her  thigh  bone  about  the  middle. 
The  leg  was  put  in  a  posterior  wire  splint  extending  from  the  hip 
to  the  ankle.  Beck's  extension  of  nine  pounds  was  applied.  She 
sat  up  in  bed  during  the  first  week.  After  three  weeks  the  splint  and 
extension  were  taken  off  during  the  day  time  but  reapplied  during 
the  night.  After  a  week  of  this,  the  patient  was  allowed  to  go  about 
on  crutches.  It  was  noticed  then  that  the  injured  leg  was  shorter 
than  its  fellow.    Her  general  health  has  always  been  good. 

Examination. — 'The  patient  is  a  fine  husky,  energetic  lassie,  the 
very  picture  of  health.  As  she  walks  there  is  apparent  a  marked 
tilting  of  the  pelvis.  IMeasurement  shows  more  than  two  inches  of 
shortening.  The  x-ray  shows  a  corresponding  overlapping  of  the 
broken  ends  (Fig.  243).    The  urine  is  cloudy  and  contains  pus  cells. 

Diagnosis. — The  condition  is  obvious.  The  degree  of  shortening  is 
such  as  to  prove  disfiguring,  though  the  patient  is  not  disturbed 
otherwise. 


408 


CLTXICAL   ST'RGERV   BY    CASE    HISTORIES 


Treatment. — The  area  of  overlapping  was  approached  from  the 
lateral  side  near  the  insertion  of  the  vastus  lateralis.  The  upper 
fragment  is  posterior  and  medial  to  the  lower.  The  union  separated 
and  the  ends  squared  off.  After  they  were  approximated,  a  steel 
plate  was  applied.  A  board  splint  was  applied  from  the  crest  of  the 
ilium  to  the  ankle,  and  a  short  one  on  the  inside  extending  from  the 
pubes  to  the  knee. 


Fig.  243. — Malunion  in  fracture  of  the  femur. 


DISEASES   OF    THE   LOWER   EXTREMITIES  469 

After-course. — At  the  end  of  a  week  the  splints  were  in  place  and 
the  alignment  of  the  bones  satisfactory.  At  the  end  of  the  second 
week  it  was  noticed  that  the  lateral  splint  had  slipped  about  to  the 
anterior  lateral  aspect  and  that  the  bone  had  angulated  laterally 
(Fig'.  244).  To  overcome  this,  lateral  traction  was  made.  A  weight 
as  heavy  as  fourteen  pounds  Avas  tolerated.  The  result  was  a  dis- 
turbance of  the  new  wound  from  pressure  of  the  soft  parts  against 
the  plate.  The  plate,  therefore,  was  removed.  The  Avound  so  pro- 
duced became  infected  and  the  cast  now  applied  had  to  have  a 
large  window  to  permit  dressing  of  the  wound.  The  angulation  was 
reproduced  into  this  window,  and  a  considerable  deformity  re- 
sulted.     The   ends   of   the   bones   remained   in   apposition   but   the 


tig.  244. — Lateral  displacement   of  fragments. 

angulation  was  so  great  that  a  total  shortening  of  2  inches  re- 
mained. Because  of  the  state  of  the  wound,  enough  lateral  pres- 
sure could  not  be  applied  to  correct  the  deformity,  and  this  state 
was  allowed  to  persist  with  the  attendant  shortening. 

Comment. — The  result  of  our  labors  to  date  is  the  approximation 
of  the  ends  of  the  fragments  and  the  substitution  of  an  angular 
deformity  instead  of  an  overlapping.  The  advantage  is  that  it  is 
now  possible  by  a  linear  osteotomy  to  spring  the  bone  into  place 
and  retain  it  with  a  cast.  Such  a  small  wound  will  make  the  use 
of  a  close  fitting  cast  possible.  The  primary  difficulty  in  these 
cases  comes  from  the  shortening  of  the  adductor  group  of  muscles. 
Because  of  this  shortening,  there  is  a  tendency  to  buckle  the  un- 
united fragments  outward.  Because  the  wound  is  placed  laterally, 
enough  counterpressure  can  not  be  applied  to  overcome  this  ten- 


470  CLINICAL   SURGERY   BY    CASE    HISTORIES 

dency.  If  the  incision  had  l)een  made  through  the  top,  going 
through  the  rectus,  as  is  often  done,  this  would  have  been  avoided, 
but  the  rectus  would  have  been  so  involved  in  adhesions  that  flex- 
ion and  extension  of  the  leg  would  have  been  lessened.  A  section  of 
the  adductor  tendons  at  the  pubic  arch  was  considered.  The  position 
seemed  to  be  so  well  retained  at  the  time  of  operation  that  this  was 
deemed  unnecessary.  It  likely  would  have  been,  had  not  the  lateral 
splint  slipped  out  of  its  place,  allowing  the  bone  to  buckle  under 
it.  All  this  might  have  been  obviated  perhaps  by  placing  a  complete 
east  from  the  pelvis  to  the  ankle  at  the  time  of  operation.  These 
large  wounds  are  always  folloAved  ]\v  more  or  less  exudation,  which 
makes  a  change  of  the  outer  dressing  desirable  after  a  few  days, 
which  would  have  been  impossible  without  making  a  window  so 
large  as  to  negate  the  lateral  pressure  effect  of  the  cast.  Perhaps  a 
compromise  might  have  been  effected  by  using  a  removable  cast 
so  that  the  dressings  could  have  been  changed  and  the  cast  re- 
applied. My  usual  practice  is  to  allow  the  cast  to  remain,  the 
secretions  being  allowed  to  dry  in  the  dressings.  This  patient 
being  unusually  nervous  and  unusually  vivacious,  and  it  may  be 
added,  very  attractive,  everything  was  done  to  lessen  the  irritation 
to  which  she  would  be  subjected.  The  only  principle  to  follow 
is  to  place  the  limb  after  the  plate  has  been  applied  into  a  cast  that 
will  hold  it  rigid,  and  forget  every  other  consideration. 

CASE  9. — A  farmer  aged  twenty  came  to  the  hospital  because  of 
a  discharging-  sinus  of  the  right  thigh. 

History. — When  nine  years  old  he  became  sick,  with  a  high  fever. 
He  had  a  pain  in  his  right  knee.  This  was  treated  for  rheumatism. 
He  gradually  improved,  but  the  fever  and  pain  continued.  At  the 
end  of  four  weeks  he  developed  a  swelling  above  the  knee  on  the 
outside.  This  was  opened  and  much  pus  ran  out.  After  this  he 
improved  more  rapidly.  The  opening  continued  to  discharge. 
It  would  close  and  after  a  few  weeks  would  become  painful  and 
begin  to  discharge  again.  After  three  years  he  was  taken  to  a 
surgeon  who  made  an  incision  and  scraped  the  bone.  The  wound 
closed  except  at  one  point  where  the  discharge  continued  as  be- 
fore. This  operation  was  repeated  on  two  more  occasions  with 
the  same  result,  the  last  time  three  vears  ago.     When  the  wound 


DISEASES    OF    THE    LOWER    EXTREMITIES  471 

is  discharging  he  feels  quite  well,  but  when  it  closes  he  soon  begins 
to  have  pain.    His  health  otherwise  has  always  been  good. 

Examination. — The  patient  is  a  husky  lad  and  one  is  rather  sur- 
prised to  hear  such  a  long  tale  of  woe.  Just  above  the  external 
condyle  is  a  fistulous  opening  from  which  a  small  amount  of  thin 
pus  is  escaping.  Extending  upward  from  this  is  a  series  of  scars 
about  six  inches  long.  The  muscles  of  the  thigh  seem  less  firm, 
and  less  perfectly  developed  than  those  of  the  opposite  leg.  The 
bone,  on  the  contrary,  seems  double  the  thickness  of  its  fellow. 
His  pulse  the  first  day  in  the  hospital  varied  from  70  to  80,  and 
the  temperature  was  normal,  the  urine  negative.  The  blood  count 
presented  nothing  of  interest. 

Diagnosis. — Obviously  the  patient  had  a  much  neglected  osteomye- 
litis.    The  generalized  thickening  of  the  femur  indicates  that  there 


Fig.   245. — Necrotic  bone   removed   from   a   chronic   osteomyelitis. 

must  be  a  seciuestrum  involving  a  greater  part  of  the  femur.  In  the 
absence  of  the  x-ray  the  extent  of  the  thickening  had  to  be  accepted 
as  the  guide  to  the  extent  of  involvement.  There  was  evidently 
no  toxic  absorption  going  on  because  of  the  state  of  the  blood  and 
because  of  the  absence  of  a  rise  in  temperature.  He  was  regarded, 
therefore,  as  being  in  a  favorable  condition  for  operation. 

Treatment. — Under  ether  an  incision  was  made,  beginning  below 
the  great  trochanter  and  circumscribing  the  fistulous  opening  above 
extending  to  the  external  condyle.  The  shaft  of  the  bone  was  freed  for 
half  its  circumference.  It  was  noticed  that  this  exposed  aU  of  the  bone 
where  the  circumference  was  corrugated  and  uneven,  indicating  that 
the  exposure  was  sufficient.  With  an  inch  carpenter's  chisel  the 
bone  was  rapidly  tunneled  throughout  its  length.  This  exposed  a 
seciuestrum  extending  nearly  the  entire  length  of  the  opening.  This 
was  removed  ^^-ith  forceps.  The  tunneled  bone  was  then  vigorously 
curetted  and  the  cavitv  cauterized  with  carbolic  acid  for  one  minute 


472  CLINICAL   SURGERY    BY    CASE    HISTORIES 

and  then  filled  with  alcohol  which  was  allowed  to  remain  five  minutes. 
The  soft  parts  were  then  closed,  save  for  an  opening  two  inches 
long  at  the  lower  termination  of  the  wound.  This  was  loosely  packed 
with  gauze.     The  amount  of  hlood  lost  was  not  great. 

Pathology. — The  sequestrum  was  broken  in  several  pieces  during 
removal.  It  was  friable  and  contained  many  uneven  areas  where 
the  granulations  had  invaded  it  (Fig.  245). 

After-course. — The  patient  was  profoundly  shocked.  His  pulse 
mounted  to  150,  the  respiration  to  40,  while  the  temperature  was 
subnormal.  He  was  given  morphine  and  atropine  and  three  doses 
of  tr.  strophanthus  (IT],  xv)  subcutaneously.  In  ten  hours  his  pulse 
dropped  to  120,  the  respiration  to  22  and  the  temperature  rose  to 
102°.  After  this,  recovery  was  uneventful.  There  was  considerable 
discharge  from  the  wound  when  the  pack  was  removed  after  a  w^eek. 
This  contained  staphylococci.  He  returned  home  on  the  twenty- 
fourth  day  Avith  but  a  little  discharge  from  the  drainage  wound. 
Three  years  later  he  returned  because  he  had  had  pain  in  his  leg 
for  a  week.  The  x-ray  failed  to  show  a  focus  and  he  had  no  rise 
of  temperature  and  without  treatment  the  pain  subsided  and  he 
has  remained  free. 

Comment. — It  is  important  in  planning  the  removal  of  large  se- 
questra to  begin  the  operation  on  a  large  scale  that  the  work  may  be 
expeditiously  accomplished.  Wliere  a  big  job  is  to  be  done,  a  big 
incision  and  big  tools  save  time.  Shock  is  the  factor  to  be  feared. 
The  profound  shock  in  this  case  caused  me  to  search  for  some 
method  to  prevent  it.  The  first  step  was  to  combine  local  anesthesia 
with  ether,  the  last  step  to  do  the  entire  operation  under  spinal  an- 
esthesia. Shock  does  not  follow  operations  done  under  this  anes- 
thesia. 

CASE  10. — A  newspaper  man  aged  forty-two  came  for  relief  from 
a  discharging-  sinus  above  his  knee. 

History. — When  eleven  years  old  he  had  an  inflammatory  affection 
below  his  left  knee.  After  treatment  for  some  weeks  the  leg  was 
amputated  above  his  knee.  Some  months  later  the  remaining  leg 
became  inflamed  about  and  above  the  knee.  After  an  interval  of  a 
number  of  weeks  a  discharging  sinus  formed.  This  has  discharged 
at  intervals  since.    Despite  this  his  health  has  remained  good. 

Examination. — There  is  a  discharging  sinus  medial  to  the  internal 


DISEASES    OF    THE   LOWER   EXTREMITIES 


473 


Fig.   246. — Chronic   osteomyelitis  of  the  femur. 


474  CLINICAL   SURGERY-   BY    CASE    HISTORIES 

hamstring  tendon.  There  are  numerous  scars  above  the  outer  con- 
dyle. The  bone  feels  thickened  throughout  most  of  its  extent.  This 
is  confirmed  by  the  x-ray  (Fig.  246).  The  x-ray  shows  involvement 
of  most  of  the  shaft.  The  examination  of  the  heart  and  urine  show 
no  abnormalities. 

Diagnosis. — The  presence  of  an  old  osteomyelitis  is  apparent  at  a 
glance.  In  such  long-standing  processes  cardiac  and  renal  complica- 
tions, often  marked,  are  apt  to  develop.  There  is  no  evidence  of 
such  complications  here,  and  he  appears  to  be  a  fit  candidate  for  op- 
eration. Because  of  the  long  duration  and  thickness  of  the  bone 
this  will  he  formidable. 

Treat mrnf. — A  long  incision  was  made  along  the  lateral  border 
of  the  thigh.  The  labor  required  to  chisel  open  the  dense  bone  was 
considerable.  It  was  tunneled  for  some  10  inches.  A  large  quantity 
of  necrotic  bone  was  removed.  The  bone  was  treated  with  carbolic 
acid  and  alcohol.  Much  blood  was  lost  while  clearing  out  the  bone 
bed. 

Pathol ogfj. — The  bone  removed  consisted  of  many  small  particles 
surrounded  by  granulation  tissue. 

After-course. — After  the  operation  the  patient  became  profoundly 
shocked  and  remained  so  for  nearly  twenty-four  hours.  It  seemed 
he  surely  would  die.  He  finally  recovered  and  the  wound  healed 
without  notable  disturbance.    A  small  sinus  remained  for  many  years. 

Comment. — There  is  no  class  of  operations  so  uniformly  attended 
by  shock  as  these  thigh  operations.  This  is  in  part  due  likely  to  the 
general  systemic  disturbance  produced  by  prolonged  suppuration. 
The  use  of  spinal  anesthesia  does  away  M^th  this  shock  and  is  impera- 
tively demanded  in  these  operations. 

DISEASES  OF  THE  REGION  OF  THE  KNEE 

The  region  of  the  knee  is  prolific  of  surgical  affections  of  an  im- 
portant nature.  The  internal  derangements  are  many  and  impor- 
tant and  difficult  to  interpret.  Loose  cartilages  and  floating  bodies 
must  always  be  thought  of  before  an  inflammatory  affection  is  diag- 
nosticated. Suppurative  infections  are  dangerous,  but  their  pres- 
ence must  be  accepted  with  reserve  lest  one's  efforts  add  what  was 
only  suspected.     Cystic  tumors  must  be  considered  to  be  connected 


DISEASES    01'    THE    LOWER    EXTREMITIES  475 

with,  the  joint  cavity,  and  solid  tumors  must  be  regarded  as  some 
form  of  sarcoma,  and  the  necessary  operatiA-e  precautions  obserA^ecl. 

CASE  1. — A  farmer  boy  aged  nineteen  was  brought  to  the  hospital 
because  of  a  painful  swelling  of  his  knee. 

Histori/. — Two  days  ago  wliile  out  hunting  he  ran  a  hedge  thorn 
into  his  knee  just  above  and  lateral  to  the  patella.  He  does  not 
know  how  deeply  the  thorn  penetrated  or  whether  or  not  it  was 
broken  off.  During  the  night  following  injury  he  had  a  pro- 
nounced chill  and  the  knee  became  markedly  swollen  and  very  painful. 
While  hunting  he  became  thoroughly  soaked  and  was  much  chilled 
when  he  arrived  home.  Save  for  a  number  of  attacks  of  tonsillitis 
he  has  always  been  well.  He  complains  of  a  severe  general  aching, 
particularly  along  the  spine. 

Examination.- — There  is  pronounced  exudate  into  the  joint.  The 
point  of  entrance  of  the  thorn  is  half  an  inch  above  and  an  inch  me- 
dial to  the  proximal  end  of  the  patella.  There  is  a  zone  of  deep  red- 
ness about  the  point  of  entrance.  The  whole  knee  is  acutely  sensi- 
tive to  touch  and  the  area  about  the  entrance  of  the  thorn  is  doubly 
so.  No  other  joints  are  affected  and  his  throat  is  not  sore.  The  tem- 
perature was  103.5°,  pulse  120,  respiration  22;  the  leucocyte  count 
8,000,  the  poh'nuclears  not  exaggerated. 

Diagnosis. — The  eiddeuce  of  trauma  made  it  appear  that  we  had 
to  do  with  an  infective  arthritis.  However,  the  onset  seemed  too 
sudden  and  the  pain  too  acute  for  an  infection  so  early  in  its  course 
unless  the  infection  should  be  unusually  virulent,  which  is  usually  not 
the  case  in  hedge  thorn  infections.  The  leucocyte  count  did  not 
support  such  an  assumption.  It  was  decided,  therefore,  to  await 
developments  for  a  day. 

Treatment. — Lead  acetate  solution  was  used  as  a  temporary  treat- 
ment. 

After-course. — During  the  following  night  he  had  another  chill  and 
the  knee  of  the  opposite  leg  became  involved  as  did  the  shoulder  and 
elbow  of  the  opposite  side.  A  diagnosis  was  then  made  of  acute 
rheumatism  and  the  salicylates  were  begun.  There  still  remained 
the  possibility  that  the  thorn,  if  it  did  penetrate  into  the  joint  cavity, 
might  cause  a  secondary  infection  and  a  multiple  polyarthritis  from 
infection.  The  painful  joints  including  the  one  bearing  the  thorn 
prick  responded  promptly  to   the   salicylates   and  subsequently  ran 


476  CLINICAL   SURGERY   BY    CASE    HISTORIES 

a  typical  course.     His  tonsils  were  remoYed  after  lie  reeoYercd  from 
his  rheumatism. 

Comment. — In  general  it  may  be  said  that  there  is  no  septic  proc- 
ess that  produces  the  intense  suffering  that  a  beginning  rheumatic 
affection  does.  A  penetrating  wound  requires  from  24  to  48  hours  to 
produce  a  considerable  degree  of  reaction. 

CASE  2. — A  retired  farmer  entered  the  hospital  because  of  a  tu- 
mor on  the  back  of  his  leg. 

History. — FIyc  years  ago  he  first  noticed  a  hard  egg-shaped  tumor 
back  of  his  knee.     It  has  grown  stead Hy  since.     It  has  ncYer  caused 


Fig.   247. — Fibroliposarcoma  of  the  popliteal  space. 

pain,  neither  has  the  foot  swollen.  He  has  a  small  hard  tumor  below 
his  left  shoulder.  This  has  been  present  many  years  and  does  not 
grow. 

Examination. — In  the  popliteal  space  is  a  tumor  5x3x3  inches 
(Fig.  247).  It  is  dense,  elastic,  and  presses  the  hamstring  tendons 
to  one  side.  It  is  unattached  to  the  skin,  but  seems  to  be  ciuite 
firmly  fixed  in  the  depth.  The  Ycins  of  the  leg  are  not  enlarged. 
The  x-ray  shows  the  bone  to  be  free. 

Diagnosis. — The  tumor  lies  exactly  in  the  popliteal  space,  and  is 
CYidently  definitely  expansile  in  growth.  It  is  lower  and  is  less 
firm  than  the  usual  fibro-sarcomas  of  the  sciatic  nerYcs.  The  probable 
diagnosis  seemed  to  1)e  myxosarcoma.  Despite  the  fact  that  it  seems 
to  be  firmly  fixed  to  the  bottom  of  the  popliteal  space,  the  fact  that 


DISEASES    OF    THE   LOWER   EXTREMITIES 


477 


none  of  the  veins  in  the  neighborhood  are  dilated  is  proof  that 
there  is  no  invasion  and  that  likely  its  removal  can  be  effected 
without  endangering  the  large  veins. 

Treatment. — ^Removal.  When  exposed,  the  large  nerves  lay  on  its 
surface.  By  beginning  above  and  locating  the  vessels  it  was  possible 
to  separate  the  tumor  from  them  without  more  injury  than  the 
tearing  loose  of  a  few  small  branches. 


Fig.   248. — Fibroliposarcoma  of  the  popliteal  space. 

Pathology. — The  tumor  is  soft  and  distinctly  yellow  in  color  but 
there  are  areas  of  more  pinkish  color  that  are  translucent  (Fig.  248). 
Many  tibrous  bundles  traverse  the  tumor,  and  when  the  tumor  is  cut 
across,  many  fibrous  areas  are  seen.  Section  shows  the  yellow  area 
to  be  fat,  the  pink  areas  myxoid,  and  fibrous  areas  to  be  fibers  with 
but  a  few  long  spindleform  cells.  The  tumor  may  be  regarded, 
therefore,  as  a  lipofibrosarcoma. 

After-course. — The  wound  healed  promptly,  and  the  patient  has 
remained  free  from  recurrence. 


478  CLINICAL   SURGERY   BY    CASE    HISTORIES 

Comment. — Tumors  containing  myxoid  tissue  in  this  region  are 
very  prone  to  recur,  notwithstanding  the  sections  may  fail  to  show 
other  than  myxoid  tissue.  A  guarded  prognosis,  therefore,  should 
always  be  made,  no  matter  what  the  pathologist  has  to  say.  I  once 
saw  a  patient  who  had  been  operated  on  no  less  than  twelve  times 
for  recurring  myxoma  of  the  adductor  region  of  the  thigh  before 
definitely  sarcomatous  tendencies  became  manifest.  These  tumors, 
therefore,  should  not  be  "shelled  out"  though  they  are  well  limited 
against  the  surrounding  tissue,  but  the  capsule  should  be  dissected 
out  with  the  tumor. 

CASE  3. — A  housewife  aged  forty-eight  was  brought  to  the  hospi- 
tal because  of  a  tumor  back  of  the  right  knee. 

History. — Her  trouble  began  about  10  or  12  years  ago.  She  first 
noticed  that  the  space  back  of  the  right  knee  was  larger  than  the 
left.  It  caused  no  trouble  at  that  time.  During  the  past  j'ear  it 
has  enlarged  rapidh^  and  caused  her  foot  to  tire  on  that  side  when 
she  was  on  her  feet.  fSix  months  ago  the  ankle  swelled  and  she 
had  pain  which  would  run  do^^i  to  the  top  of  the  foot.  There  was 
sometimes  also  a  burning  sensation.  For  a  month  past  she  can  not 
step  on  the  leg  at  all.  l^ecause  she  can  not  straighten  it  out.  Her 
weight  remains  about  the  same  as  usual.  She  can  not  sleep  on 
account  of  the  pain.  She  has  used  morphine  tablets  the  past  week 
for  pain. 

Examination. — A  tumor  mass  occupies  the  right  popliteal  space  and 
extends  ujjward  about  8  or  10  inches.  It  is  movable  laterally  but  not 
upwards  and  downwards.  The  general  appearance  of  the  patient  is 
not  good ;  she  has  an  anxious,  apprehensive  expression.  Urine  nega- 
tive. White  blood  count  10,000.  The  x-ray  shows  the  bone  to  be 
free  from  the  tumor. 

Diagnosis.- — The  position  of  the  tumor  and  its  recent  rapid  growth 
indicates  that  it  is  a  sarcoma.  The  chief  problem  to  determine  is  its 
relation  to  the  sciatic  nerve.  The  pain  it  has  caused  would  in- 
dicate that  it  springs  from  the  nerve,  for  a  tumor  as  soft  as  this 
one  should  not  cause  so  much  pain  by  simple  compression.  The  lateral 
mobility  and  its  fixity  in  other  directions  point  the  same  way.  Being 
so  the  removal  of  the  tumor  most  likely  will  require  a  resection 
of  the  nerve  with  a  comj^lete  loss  of  nerve  supply  to  the  foot.  There- 
fore amputation  is  indicated.    The  patient  protested  so  strenuously 


DISEASES    OF    THE   LOWER   EXTREMITIES 


479 


and  promised  to  submit  to  amputation  later  if  the  results  were  not 
satisfactory. 

Operation. — Eesection  of  the  tumor  mass  under  spinal  anesthesia 
was  done.  It  shelled  out  fairly  well  except  when  the  nerve  was 
approached.  The  peroneal  and  posterior  tibial  nerves  were  cut  below 
in  removing  the  tumor  and  the  sciatic  above.  The  large  vessels  were 
not  involved. 


Fig.   249. — Myxosarcoma  of  the   sciatic  nerve. 


480  CLINICAL   SURGERY   BY    CASE    HISTORIES 

PatJiologij. — The  tumor  was  a  laryc,  soft,  lobiilated  mass  (Fig.  249) 
which  ill  parts  was  p-rayish  white,  in  others  pink  and  almost  transhi- 
ceiit.  The  cut  surface  showed  lobulations,  being  in  part  pale  pink  and 
translucent,  in  part  grayish  white.  When  the  former  came  in  con- 
tact w^th  the  nerve,  the  fibers  seem  to  be  but  pushed  aside,  but 
when  it  was  in  contact  ^vith  the  grayish  parts  there  was  evidence  of 
invasion.  The  slides  showed  a  typical  myxoma  for  the  pink  area  and 
a  more  cellular  area  where  it  was  present.  Fig.  250  represents  the 
borderline  between  the  two  areas.    It  is  a  myxosarcoma. 

After-course. — Healing  was  uneventful.     Sensation  was  lost  over 


the  dorsum  of  foot  and  the  lower  outer  aspect  of  leg,  plantar  surface 
of  foot.  There  was  foot-drop  and  the  foot  swelled.  She  was  unable 
to  use  the  foot. 

The  patient  returned  after  three  months  with  a  swelled,  useless 
limb.  She  is  unable  to  bear  weight  on  it  because  there  is  no  sensa- 
tion and  she  can  not  tell  when  it  is  rightly  placed.  She  returned 
six  months  after  operation  and  there  was  a  recurrence  in  the  low^er 
angle  of  the  incision.  She  now  desired  amputation.  There  was  a 
mass  the  size  of  a  hen's  egg  in  the  supraclavicular  fossa  and  further 
treatment  was  refused. 

Comment. — Primai-y  amputation  should  have  been  insisted  upon. 
The  patient  was  so  insistent  that  local  removal  be  tried  and  having 


DISEASES    OF    THE   LOWER    EXTREMITIES 


481 


never  observed  a  leg  in  which  the  sciatic  nerve  was  severed  I  was 
not  wholly  unwilling  to  accede  to  her  wishes.  I  reasoned  that  being  a 
myxoma  there  would  at  most  be  a  local  recurrence  which  would  admit 
of  amputation  and  the  patient  would  only  be  put  to  the  inconvenience 
of  a  second  operation.  I  did  not  anticipate  a  constitutional  metas- 
tasis. 

CASE  4. — A  laborer  aged  thirty-six  came  because  of  ulcers  on  his 
knee. 

History. — Six  weeks  ago  his  knee  below  the  knee  cap  became  sore 
and  two  weeks  ago  formed  ulcers.  The  ulcers  are  somewhat  painful, 
but  not  markedly  so. 

Examination. — Over  the  tuberosity  of  the  tibia  is  a  reddened  area 


Fig.   251. — Gummas  of  the  knee. 


482  CLINICAL   SURGERY  BY   CAS£   HlSTOtttES 

as  large  as  the  palm  of  the  hand.  Within  this  area  of  redness  are 
four  ulcers  the  size  of  a  butter  bean  and  several  smaller  ones.  The 
two  largest  are  reniform  (Fig.  251)  punched-out  with  soft  walls  and 
dirty  bases.  The  conglomerate  arrangement  of  these  forms  a  kidney- 
shaped  outline. 

Diagnosis. — The  form  of  the  individual  lesions  and  the  grouping 
of  the  whole  is  characteristic  of  gumma. 

Treatment. — Mercurial  plaster  locally  and  potassium  iodide  inter- 
nally until  the  lesion  heals,  then  mercury. 

Comment. — The  method  employed  probably  interfered  less  than 
any  other  with  the  pursuance  of  his  daily  tasks.  It  is  quite  possible 
that  mercury  still  presents  our  most  reliable  ultimate  cure  for  syph- 
ilis. At  any  rate,  one  should  not  be  regarded  as  culpable  if  he  fails 
to  use  salvarsan. 

CASE  5. — A  merchant  aged  fifty  came  to  the  hospital  because  of 
a  painful  and  stiff  knee. 

History. — -While  stepping  over  a  fence  two  feet  high  six  years 
ago  he  slipped,  and  in  the  effort  to  prevent  a  fall,  he  felt  a  pain  in 
his  left  knee.  He  had  some  pain  for  a  few  days  following,  and  as  the 
pain  ceased  he  noticed  that  the  knee  was  swollen.  For  four  years 
following  this  he  was  able  to  use  the  leg,  but  at  irregular  intervals 
the  leg  became  locked  so  that  he  was  unable  to  move  it.  After  a  few 
moments  of  intense  pain  he  would  be  able  to  walk  again.  At  inter- 
vals during  this  period  the  knee  swelled.  Four  years  ago  while  the 
knee  was  swollen  more  than  usual  he  consulted  a  surgeon  who  aspi- 
rated several  ounces  of  fluid.  He  diagnosed  a  loose  body  and  opened 
the  knee.  No  loose  body  was  found.  Following  the  operation  the  knee 
became  quite  stiff  and  a  year  later  the  joint  was  moved  under  an 
anesthetic.  The  movement  improved  some,  but  there  was  constant 
pain  instead  of  pain  only  occasionally  as  before  the  operation.  Subse- 
quently the  tissues  about  the  joint  were  injected  by  an  irregular 
practitioner.  The  patient  was  told  that  the  fluid  did  not  enter 
the  joint.  He  is  certain  of  the  fact  only  that  much  pain  and 
inflammation  followed  these  injections.  Two  years  ago  he  consulted 
an  eminent  surgeon  who  drew  off  some  fluid  and  injected  iodoform 
emulsion.  This  was  repeated  three  times  at  intervals  of  a  month. 
The  joint  became  more  painful  and  the  movements  more  limited. 


DISEASES   OF    THE   LOWER   EXTREMITIES  483 

His  general  health  has  alwaj^s  been  good.  There  is  no  tuberculosis  in 
the  family  and  there  have  been  no  joint  infections. 

Examination. — The  appearance  of  the  patient  is  that  of  good  health. 
The  knee  is  moderately  swollen  and  both  the  thigh  and  calf  are 
smaller  and  more  flabby  than  the  opposite  leg.  The  leg  can  be 
extended  to  within  25  degrees  of  full  extension  and  can  be  flexed 
about  30  degrees.  Flexion  is  limited  by  muscular  spasm,  while  ex- 
tension seems  to  be  checked  by  fibrous  bands.  Other  than  this  he 
moves  the  leg  voluntarily  and  is  able  to  deliver  a  vigorous  kick. 
He  indicates  the  upper  border  of  the  tibial  tuberosity  as  the  site  of 
his  initial  pain  at  the  time  of  the  primary  injury.  At  the  time  of 
examination  the  entire  patellar  condyle  region  is  complained  of  as 
being  painful.  This  area  is  sensitive  to  deep  pressure.  When  the 
leg  is  passively  manipulated,  a  grating  sensation  is  imparted  to  the 
examining  hand  laid  over  the  medial  side  of  the  joint.  The  tissues 
about  the  joint  are  but  little  thickened,  the  enlargement  being  only 
apparently  due  to  the  atrophy  of  the  soft  parts  above  and  below  the 
joint.  The  maximum  circumference  is  but  an  inch  greater  than  the 
sound  knee.     No  fluid  can  be  demonstrated. 

Diagnosis. — The  initial  injury  came  while  the  joint  was  subjected 
to  an  unusual  strain  while  in  an  unnatural  position.  The  site  indi- 
cated is  that  of  the  medial  semilunar  cartilage.  The  exudate  is  in 
harmony  with  a  possible  dislocation  of  this  disc.  The  fact  that  there 
was  a  similarity  of  the  site  of  locking  of  the  joint  at  the  periods 
of  pain  subsequent  to  this  is  in  harmony  mth  this.  The  first  surgeoii 
was  not  warranted  in  diagnosticating  a  floating  body  because  none 
had  ever  been  located  at  the  time  of  the  pain,  and  floating  bodies  do 
not  first  appear  when  the  leg  is  in  an  unnatural  position.  His  failure 
to  locate  the  hypothecated  fioating  body  is  against  his  theory.  The 
second  surgeon  based  his  diagnosis  apparently  on  the  thickened  joint 
and  the  grating  sensation  felt  on  passive  movement.  The  thickening 
of  the  joint  is  not  as  great  as  one  sees  in  tuberculosis  of  the  adult,  and 
the  grating  sensation  is  more  localized  than  is  felt  in  this  disease  of 
the  knee  joint.  Furthermore,  the  joint  has  no  doubt  suffered  much 
from  previous  efforts.  Notwithstanding  the  opinion  of  this  eminent 
authority,  the  diagnosis  of  tuberculosis  can  not  be  accepted.  The 
failure  to  secure  results  from  the  iodoform  injections  can  not  be 
counted  against  this  theory,  for  such  therapeutics  are  uniformly  un- 
successful in  tuberculosis  of  the  adult.     The  one  outstanding  feature 


484  CLINICAL   SURGERY   BY    CASE    HISTORIES 

available  for  diagnosis  is  the  history  of  the  primary  injury — sudden 
pain  while  the  leg  was  in  excessive  strain  in  an  unnatural  position. 
The  diagnosis  must  be  a  dislocated  semilunar  cartilage. 

Treatment. — A  long  incision  was  made  over  the  joint  parallel  with 
the  long  axis  of  the  leg.  The  joint  was  exposed  by  a  wide  retraction  of 
the  tissue.  The  semilunar  cartilage  was  entirely  loosened  except  for 
less  than  an  inch  at  its  posterior  extremity.  The  anterior  portion 
was  represented  by  mere  fragmentary  bands  while  the  middle  por- 
tion Avas  rolled  up  and  lay  behind  the  condyle  of  the  femur.  Flexion 
of  the  leg  on  the  thigh  forced  this  mass  upward  against  the  condyle. 
The  articular  surface  of  the  femur  in  this  region  was  partly  destroyed 
and  it  was  the  movement  of  this  injured  cartilage  that  caused  the 
grating  sensation  detected  on  the  first  examination.  The  entire  cartil- 
age was  removed  and  the  incision  closed  without  drainage. 

Pathology. — The  ball  of  tissue  removed  was  an  exceedingly  dense 
fibrous  tissue  without  any  definite  structure  but  without  any  calca- 
reous deposit. 

After-coxrse. — The  patient  was  free  from  pain  after  he  recovered 
from  the  operation  and  the  range  of  motion  slightly  increased,  but 
full  extension  was  never  attained. 

Comment. — A  careful  history  in  joint  affections  is  of  as  great  im- 
portance as  the  physical  examination.  A  loose  body  should  not  b? 
diagnosticated  unless  its  presence  has  been  actually  demonstrated. 
Even  though  one  feels  sure  of  a  loose  body  the  semilunar  cartilages 
should  be  identified  and  examined  before  a  search  is  instituted  for 
the  floating  body. 

CASE  6. — An  oil  man  aged  thirty  came  to  the  hospital  because  of 
swelling-  of  the  right  knee  joint  and  pain  in  the  right  leg. 

History. — Past  history  is  negative.  The  present  trouble  was  caused 
by  the  penetration  of  a  steel  jacketed  32  automatic  bullet  through  the 
thigh  just  above  the  knee  joint  and  just  back  of  midline  of  the 
thigh.  The  bullet  entered  the  outer  side  of  the  thigh  and  came  out 
on  the  inner  side.  One  bullet  also  went  through  the  quadriceps 
muscle  above,  on  the  right  thigh,  and  one  on  the  left.  No  particu- 
lar swelling  or  trouble  developed  and  the  wound  healed  completely 
without  infection. 

One  month  after  injury,  the  knee  began  to  swell  and  he  had  pain 
in  the  right  leg  and  foot.     The  knee  was  plastered  with  antiphlogis- 


DISEASES    OF    THE   LOWER    EXTREMITIES 


485 


tine  and  in  two  weeks  the  swelling  began  to  subside,  but  a  week 
elapsed  before  it  was  entirely  gone.  This  swelling  took  four  to 
five  daj^s  coming  on.  He  got  up  and  walked  around  after  the 
swelling  went  down.  A  week  before  entering  the  hospital  he 
walked  around  in  some  slippery  mud,  leading  horses,  and  that  night 
had  some  pain  in  the  knee.  The  next  morning  he  had  a  big  swelling 
back  of  the  knee  extending  around  the  thigh  on  both  sides.  This 
came  on  during  the  night  and  never  became  larger.  He  could  not 
walk  on  the  leg  and  foot.  Very  little  pain  in  the  knee  itself. 
General  health  excellent.    No  other  trouble. 


Fig.    252. — False   aneurysm   of   the    right   popliteal    artery. 

Examination. — There  is  a  large  swelling  in  the  right  popliteal 
space  which  extends  around  on  each  side  (Fig.  252).  When  taken  in 
the  flat  hand  a  distinct  pulsation  can  be  felt  in  the  swelling.  Lis- 
tening over  it  with  a  stethoscope  a  loud  bruit  is  heard.  The  x-ray 
shows  the  bones  to  be  normal. 

Diagnosis. — The  active  pulsation  proves  it  to  be  an  aneurysm  and 
having  developed  after  a  trauma  it  most  likely  is  a  false  one.  Were 
it  an  abscess,  as  the  family  doctor  thinks,  the  pulsation  would  not  be 
so  marked  and  there  should  be  evidence  of  absorption.  Furthermore, 
abscesses  in  this  region  do  not  remain  so  circumscribed.  At  any  rate, 
when  in  doubt,  look  out  for  aneurysm. 


486  CLINICAL   SURGERY   BY    CASE    HISTORIES 

Treatment. — An  incision  was  made  just  above  the  mass  in  the  pop- 
liteal space  and  then  carried  down  over  it.  The  artery  was  found 
and  ligated  with  silk.  The  mass  was  then  carefully  opened.  It  was 
a  very  large  clot  of  blood.  This  was  scooped  out. and  the  artery  fol- 
lowed do^\^l  the  po]iliteal  space.  A  hole  was  found  in  the  artery 
about  3/8  of  an  inch  in  length.  The  hole  was  oval  shaped,  the  long 
axis  parallel  to  the  long  axis  of  the  artery.  A  ligature  was  placed 
below  this  opening.  The  blood  was  all  cleaned  out,  a  large  gauze 
pack  inserted  in  the  cavity,  and  the  wound  closed.  A  bullet  had 
grazed  the  artery  probably  burning  it  and  the  artery  had  eroded 
through,  or  rather  the  piece  had  necrosed  out  later.  The  neighbor- 
ing connective  tissue  effectually  held  the  blood. 

After-course. — The  circulation  of  the  leg  seemed  to  be  little  im- 
paired by  the  ligation  of  the  artery.  The  foot  was  warm  the  next 
day  and  showed  no  circulatory  disturbance.  The  wound  healed 
rapidly  without  infection,  and  he  was  up  and  on  his  crutches  in  ten 
days.  In  three  months  he  was  fully  recovered  without  any  evidence 
of  trouble  whatever. 

Comment. — The  chief  difficulty  was  in  avoiding  the  vein.  The 
artery  stands  ligation  without  trouble,  but  the  vein  is  quite  another 
thing. 

CASE  7. — A  broker  aged  forty  came  to  the  hospital  because  of  a 
swollen  knee. 

History. — The  patient  is  said  by  his  physician  to  have  had  an 
abscess  of  the  prostate  ten  years  ago  Avhich  ruptured  into  the  blad- 
der. A  year  later  he  had  a  painful  testicle.  This  was  diagnosed  as 
tuberculosis  and  was  removed.  A  year  following  this  the  remaining 
testicle  became  similarly  involved  and  was  dealt  with  in  like  manner. 
The  incision  from  this  operation  did  not  heal  for  many  months. 
Two  and  a  half  years  ago  the  patient  bumped  his  knee.  The  joint 
became  painful  and  he  was  unable  to  walk  for  a  number  of  days, 
but  after  a  time  it  improved  and  remained  quite  well  for  a  number 
of  months.  It  became  sore  again  a  year  ago  and  he  consulted  a 
surgeon  who  found  the  joint  capsule  distended  and  aspirated  the 
fluid  and  injected  some  4  per  cent  formalin  and  glycerine.  The 
fluid  Avithdrawn  was  said  to  have  been  bile  colored.  This  procedure 
was  repeated  in  ten  days  and  the  leg  was  kept  in  a  cast  for  the  suc- 
ceeding six  months.  Despite  this  treatment,  the  knee  continued 
swollen  and  painful.    His  general  health  has  i-emained  good. 


DISEASES   OF    THE   LOWER   EXTREMITIES  487 

Examination. — The  knee  is  much  enlarged,  feels  boggy  and  semi- 
fluctuating.  There  is  no  tenderness  on  manipulation  but  there  is 
some  pain  on  movement.  The  leg  can  be  flexed  to  about  50  degrees. 
There  is  some  grating  as  the  knee  is  flexed.  The  muscles  both  above 
and  below  the  joint  are  flabby  and  atrophied  which  emphasizes  the 
enlargement  of  the  joint. 

Diagnosis. — The  testicular  affection  probably  was  tuberculous,  for 
the  surgeon  who  had  him  in  charge  is  competent.  The  primary 
trouble  with  the  knee  likely  was  traumatic,  and  the  free  interval 
represents  the  period  the  lesion  was  developing.  The  character  of 
the  fluid  removed  and  the  feeling  of  grating  as  the  knee  is  flexed 
suggests  tuberculosis.  Villous  arthritis  can  be  excluded  because  of 
the  erosion  of  the  surface  of  the  cartilage  manifest  by  grating  as  the 
knee  is  flexed. 

Treatment. — Tuberculosis  involving  so  large  a  joint  in  an  adult 
rarely  admits  of  conservative  treatment.  Hence  the  knee  joint  was 
resected.  The  bones  were  held  in  apposition  with  nails  and  the  leg 
enclosed  in  a  cast. 

Pathology. — The  capsule  was  more  than  a  centimeter  in  thickness 
and  showed  many  villous  prolongations  into  the  joint  cavity.  The 
cartilage  showed  regions  of  erosion  which  extended  down  to  the  bone. 
Microscopic  section  of  the  villi  showed  edematous  fibrous  tissue  with 
plasma  cell  infiltration. 

After-course. — Healing  was  without  event.  An  area  of  tenderness 
remained  on  the  inner  surface  over  the  tuberosity  of  the  tibia  which 
disappeared  after  a  time  and  he  has  remained  well. 

Comment. — It  is  well  in  all  instances  as  was  done  by  his  first  medi- 
cal advisor  to  treat  such  a  joint  conservatively.  Probably  it  will  not 
cure  a  tuberculous  joint,  but  it  aids  the  diagnosis,  for  simple  arthri- 
tides  will  recover  under  such  treatment.  The  diagnosis  of  swelling 
of  the  knee  with  thickened  or  apparently  thickened  capsule  is  not 
easy.  The  demonstration  of  tubercle  bacilli  in  such  lesions  is  a  task 
for  skilled  enthusiasts  with  plenty  of  leisure. 

CASE  8. — A  railway  conductor  came  to  the  hospital  because  of 
a  swelling  above  the  knee. 

History. — Seven  years  ago  he  injured  his  leg  by  being  pinched 
between  two  boxes  in  a  freight  car.  The  knee  was  sore  for  several 
weeks  following,  but  he  continued  with  his  work.     Some  years  later 


488 


CLINICAL    SURGERY    BY    CASK    HISTORIES 


he  noted  a  swelling- #just  above  the  knee.  It  swelled  but  very  slowly 
and  caused  him  no  pain  and  he  neglected  to  seek  advice.  He  still  has 
no  disturbance,  but  the  enlargement  has  been  more  rapid  in  the  last 
few  months  and  this  has  excited  his  apprehension.  His  general 
health  has  always  been  good. 

Examinaiion. — The    movements    of    the    knee    are    perfectly    free. 
There  is  a  thickeninti'  immediately  above  the  knee  beginning  iibout  lhe 


-Osteosarcoma    of    the    lower   tna    of    tli-    femur. 


middle  and  lowci-  thirds  of  the  femur  and  it  gradually  enlarges  to  at- 
tain a  maximum  size  about  six  ine-hes  above  the  condyle  (Fig.  253-A). 
It  is  very  dense,  the  surface  smooth,  not  painful  on  pressure,  and 
evidently  continuous  with  the  shaft  of  the  bone.  The  cutaneous 
veins  over  the  tumor  are  much  thickened.  The  movements  of  the 
joint  are  free  and  unhindered.  Otherwise  the  examination  is  negative. 
Diagnosis. — The  development  of  an  enlargement  of  a  bone  follow- 
ing trauma  always  suggests  the  possibility  of  sarcoma.  In  this 
case  no  enlargement  was  noticed  until  two  years  after  the  injury. 


DISEASES    OF    THE    LOWER    EXTREMITIES 


489 


The  enlargement  must  have  iDeen  very  gradual  for  after  seven 
years  the  size  is  still  inconsiderable.  The  physical  characters  are 
those  of  a  pure  osteoma  without  evidence  of  any  soft  tissue.  How- 
ever, an  osseous  tumor  involving  the  entire  shaft  of  the  bone  usually 
contains  malignant  elements.  The  localized  character  of  the  growth 
without  any  evidence  past  or  present  excludes  any  infective  process. 

Treatment. — Amputation  in  the  upper  third  of  the  thigh  was  done. 

Patliology. — AVhen  sawed  in  two  the  tumor  is  seen  to  be  composed 


Fig.  25  3-5. — Cross  section  of  osteosarcoma  of  the   knee. 


of  radiating  columns  of  bone  going  out  from  the  shaft.  The  radi- 
ating columns  seem  to  be  of  the  same  structure  and  to  be  continuous 
with  the  shaft  of  the  femur  (Fig.  253-5).  The  medulla  is  unaffected. 
The  surface  of  the  growth  was  covered  with  a  ]Deriosteal-like  mem- 
brane, and  though  thicker,  and  more  closely  attached  than  the 
normal  periosteum  of  the  shaft  above,  contains  no  evidence  of  malig- 
nancy. Examination  of  decalcified  sections  of  the  bone  showed 
nothing  suggestive  of  malignancy. 

After-course. — The  stump   healed   promptly  and  there  never  was 


490  CLINICAL   SURGERY   BY    CASE   HISTORIES 

any  sign  of  a  local  recurrence.  He  had  an  acute  sickness  a  year  and 
eight  months  after  operation  wliicli  his  doctor  diagnosed  as  pneu- 
monia. After  a  few  week  there  followed  a  slow  fehrile  process  •which 
was  diagnosed  as  tuberculosis.  He  traveled  in  the  south  without 
benefit,  but  on  the  contrary  with  gradually  failing  strength  and  ap- 
petite.    Because  of  this  he  returned  to  the  hospital. 

He  now,  twenty-two  months  after  the  amputation,  has  superficial 
respiration  and  slight  cough  with  dullness  below  the  fourth  rib,  which 
does  not  change  by  change  of  position.  Vocal  fremitus  is  lessened 
and  respiratory  sounds  are  absent.  There  are  dilated  veins  over  the 
lower  right  chest.  The  left  lung  is  negative.  The  leucocyte  count 
is  38,000  of  which  92  per  cent  are  polynuclears  and  the  temperature 
ranges  between  101  and  103.5°.  Notwithstanding  the  history  and 
probable  diagnosis  of  metastatic  sarcoma,  respect  for  the  opinion  of 
his  physician  who  in  addition  to  obtaining  pus  on  aspiration,  argued 
that  pneumonia  followed  by  failing  strength  and  high  leucocytosis 
made  empyema  certain,  I  resected  a  rib.  The  chest  was  found  to 
contain  a  solid  grayish  white  tumor.  The  patient  died  in  two  months. 
At  autopsy  the  lower  lobe  of  the  right  lung  was  found  to  have  been 
wholly  displaced  by  a  small  round-celled  tumor  with  very  little  in- 
tercellular tissue,  hence  very  friable.  A  large  amount  of  milk-like 
fluid  escaped  from  the  cut  surface.  The  mediastinum  was  not  af- 
fected. The  pleura  was  nowhere  attached,  not  even  about  the  site 
of  the  useless  rib  resection. 

Comment. — Notwithstanding  that  there  was  no  histologic  evidence 
of  malignancy,  the  clinical  course  proved  it  to  be  such  just  as  one 
could  confidently  predict  from  its  clinical  appearance.  "When  clin- 
ical and  microscopic  do  not  agree,  the  clinical  should  be  followed. 
The  acute  illness  may  have  been  a  pneumonia,  most  likely  it  was. 
Certainly  the  tumor  increased  rapidly  in  size  following.  One  can 
hardly  conceive  of  a  more  favorable  circumstance  for  rapid  growth 
in  a  neoplasm  than  the  fibrinous  environment  of  a  pneumonic  lung. 
The  consideration  of  empyema  should  never  have  been  entertained, 
for  when  a  patient  once  harbors  a  sarcoma,  any  subsequent  ill- 
ness should  be  regarded  as  a  recurrence  until  it  is  proved  otherwise. 
The  high  leucocytosis  obfuscated  my  better  judgment.  The  high  poly- 
nuclear  count  was  confusing.  The  "pus"  obtained  b}^  his  doctor  by 
aspiration  probably  was  fluid  from  the  substance  of  the  tumor. 


DISEASES    OF    THE    LOWER    EXTREMITIES 


491 


CASE  9. — A  school  girl  aged  seventeen  came  for  treatment  for 
rheumatism  in  the  right  knee. 

History. — The  patient  has  had  rheumatism  for  eleven  years.  Had 
trouble  at  six  years  in  knee.    No  pain  since  that  time  to  amount  to 


Fig.   254. — Bony  deformit}'  from  infected  arthritis  of  the  knee. 

anj^hing.  Last  attack  at  age  of  six,  vas  in  bed  one  year,  had  fever, 
knee  swollen,  painful,  could  not  move  leg.  The  leg  has  remained 
flexed  since  that  time,  no  tenderness.  At  that  time  she  had  an  opera- 
tion, scraping  of  bone.  The  patient  has  had  no  throat  trouble,  no 
cough.    Has  had  pertussis  and  chicken  pox  but  no  other  children's 


492  CLINICAL   SURGERY   BY    CASE    HISTORIES 

diseases.  Menstruation  beeran  at  age  of  fifteen,  every  thirty  days 
but  sometimes  irregular,  flow  every  three  months,  no  pain,  lasts 
three  days. 

Examination. — Patient  well  developed,  well  nourished,  does  not 
look  acutely  ill.  Eyes  react  to  light  and  accommodation.  No  dis- 
charge from  ears,  no  tophi,  teeth  in  fair  condition,  tonsils  small, 
crypts  prominent,  tongue  large  and  thick.  Xo  palpable  glands  in 
posterior  triangle  of  neck,  thyroid  palpable.  Hyperresonant  chest, 
respiration  free,  equal,  no  rales.  Heart  extends  11  cm.  to  left,  apex 
sounds  faint,  clear,  no  murmurs.  Base  sounds  normal,  no  murmurs. 
Abdomen  negative.  Right  leg  flexed  on  thigh  about  45  degrees, 
immovable,  shows  old  operative  areas,  one  on  lateral  surface  lower 
thigh,  one  medial  surface  knee,  two  anterior  medial  upper  tibia,  one 
back  of  knee.  Leg  can  be  moved  about  5  degrees  and  stops  with  a 
shock.  Knee  appears  swollen  in  comparison  with  rest  of  leg,  leg 
atrophic,  k.k.  not  obtained,  no  Babinski.  no  clonus.  The  x-ray  shows 
marked  bony  deformity  (Fig.  254).  Left  leg  movements  free.  Blood 
pressure  140-90.  Hg  70  per  cent,  white  blood  cells  19.600:  red 
blood  cells  5,680,000. 

Di<ignosis. — Ank^dosis  of  the  right  knee  joint,  the  leg  being  at  an 
angle  of  about  135  degrees  with  the  thigh. 

Treatment. — A  Y-shaped  incision  was  made  extending  from  the 
insertion  of  the  quadriceps  tendon  upward.  The  patella  was  firmly 
adherent  to  the  femur  and  was  chiseled  off  and  entirely  removed. 
A  portion  of  the  inner  condyle  of  the  femur  and  inner  head  of  the 
tibia  had  to  be  removed  before  the  leg  could  be  extended.  A  flap  of 
fascia  from  above  the  knee  was  turned  down  into  the  .joint  and 
sutured  to  the  crucial  ligaments  and  the  joint  capsule.  The  quad- 
riceps tendon  was  reunited  and  the  joint  closed.  Two  gauze  subcu- 
taneous drains  were  left. 

After-course. — The  patient  showed  no  evidence  of  postoperative 
shock  and  did  not  suffer  much  from  ether  sickness.  She  has  not  com- 
plained much  of  pain  and  rested  comfortably  the  first  night  of  the 
operation.  The  second  postoperative  day  the  temperature  was  101°, 
pulse  102  and  she  complained  of  severe  burning  pain  in  the  knee. 
This  lasted  through  the  following  day,  but  temperature  was  but 
100.5'.  pulse  100.  Temperature  did  not  rise  above  99.2°  the  rest 
of  her  stay  in  the  hospital — the  gauze  drains  were  removed  on  the 
tenth  day  through  a  window  made  in  the  east  over  the  incision.     The 


DISEASES    OP    THE    LOWER   EXTREMITIES  493 

wound  was  healing  very  slowly  and  the  sutures  were  allowed  to  re- 
main until  the  twelfth  day  when  five  were  removed.  Temperature 
was  normal  at  that  time.  The  cast  was  removed  on  the  eighteenth 
day,  there  had  been  a  good  deal  of  rotation  of  the  foot  outward  in 
the  cast.  The  foot  was  brought  into  right  angle  with  the  leg  and  in 
the  proper  position  and  a  posterior  cast  molded  to  the  lower  half  of 
the  thigh,  the  leg  and  the  foot  with  the  patient  in  a  prone  position. 
The  wound  was  dressed  and  the  remainder  of  the  sutures  removed. 
The  new  posterior  splint  caused  no  pain  in  the  knee,  but  the  patient 
complained  of  a  pain  along  the  tibia.  The  skin  looked  normal  over 
the  pain  area  and  there  was  no  swelling.  On  dismissal  one  month 
after  operation  the  wound  was  entirely  healed  except  for  two  or 
three  areas  about  the  size  of  a  dime  along  the  line  of  incision  where 
the  skin  sloughed.  The  pain  in  the  knee  and  leg  was  entirely  gone, 
temperature  and  pulse  were  normal.  The  extremity  was  straight,  the 
leg  being  in  a  line  with  the  thigh.  The  patient  had  been  up  and 
around  on  crutches  for  about  a  week.  The  right  lower  extremity 
measuring  from  the  anterior  superior  spine  of  the  ilium  to  internal 
malleolus  is  about  one  inch  shorter  than  the  left.  The  x-ray  plate 
at  dismissal  showed  no  bony  union  between  tibia  and  femur.  The 
tibia  was  set  back  so  that  the  anterior  articular  surface  of  the  tibia 
came  to  about  the  middle  of  the  articular  surface  of  the  femur. 

CASE  10. — A  man  aged  thirty-one  came  to  the  hospital  because  of 
an  injury  to  his  knee. 

History. — He  relates  that  while  riding  in  a  Ford  two  hours  ago  with 
the  top  down,  he  had  a  head  on  collision  with  an  automobile.  The  im- 
pact threw  him  over  the  windshield  of  his  own  car  and  he  alighted  on 
his  knees  on  the  radiator  of  the  attacking  car.  When  he  attempted 
to  get  up  he  found  he  could  not  bend  his  knee  and  he  fell  to  the 
ground. 

Examination. — The  right  knee  is  swollen  and  fluctuating  and  mod- 
erately sensitive  to  pressure.  There  are  a  number  of  superficial  abra- 
sions. A  mass  can  be  felt  above  the  intercondylar  groove  and  one  over 
the  tibial  tuberosity.  There  is  a  defect  in  the  normal  site  of  the 
patella.  The  x-ray  show^s  the  right  patella  to  be  broken  into  three 
fragments  (Fig.  2o5-A). 

Diagnosis. — Obviously  from  the  physical  findings  and  from  the 
x-ray  there  is  a  fracture  of  the  patella.    Fluid  free  in  the  joint  cavity 


494 


Cr.TNlCAL  SURGERY   BY   CASE   HISTORIES 


two  hours  after  injury  can  be  but  blood.  An  o^oen  operation  on  a 
joint  full  of  fresh  blood  is  a  hazardous  procedure.  Hence  any  method 
that  will  produce  coaptation  of  the  fragments  without  opening  into 
the  joints  is  to  be  preferred. 

Treatment.- — A  steel  pin  was  passed  through  the  skin  and  through 
the  quadriceps  tendon  above  the  upper  fragment.    A  similar  pin  was 


Fig.  255-^. 


-X-ray  of  the  fractured  patella  sortie  hours  after  the   injury, 
displacement   of  the  upper  fragment. 


There  is   moderate 


passed  in  like  manner  through  the  tendon  below  the  lower  fragment. 
The  two  pins  were  then  drawn  together  and  held  with  adhesive  tape 
(Fig.  255-5).  This  brought  the  fragments  in  apposition  (Fig.  255-C). 
After-course. — The  pins  were  allowed  to  remain  in  position  for 
six  weeks.    The  knee  was  manipulated  from  time  to  time  and  the 


Diseases  OP  the  lower  ExTfiEMlTlEg 


495 


muscles  massaged.  Complete  function  was  restored.  There  was  no 
limitation  of  motion  at  the  time  he  left  the  hospital  and  he  began 
at  once  to  do  the  hard  work  of  the  farm. 

Comment. — The  advantage  of  this  method  consists  in  the  fact  that 
it  can  he  used  by  anybody  anywhere.  A  couple  of  steel  iDins  and  a 
few  drops  of  a  local  anesthetic  is  all  that  is  required.     The  pins  em- 


Fig.  2S5-B. — Photograph  of  the  pins  in  position.     The  ends  are  held  in  position  by  a  number 
of   turns   of  adhesive   plaster. 


ployed  in  this  case  were  long  slender  bone  drills  and  the  handle  was 
used  in  pushing  them  into  place.  The  pins  can  be  held  together  by 
adhesive  plaster  or  a  gauze  bandage.  I  first  saw  this  method  used  by 
Dr.  G.  A.  Nickelson  of  Plains,  Kansas.  So  far  as  I  know,  the  method 
was  original  with  him. 


496 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


DISEASES   OF  THE   CALF 

The  surgical  affections  of  the  region  of  the  calf  are  chiefly 
traumatic  and  infectious.  The  tumors  of  the  soft  parts  are  usually 
sarcoid  and  those  of  the  bone,  giant-celled  sarcoma.  The  ulcerous 
lesions  require   careful   considerations   as   to   their   etiology   before 


Fig. 


255-C. — The   patellar   fragments   are   shown   in   close   coaptation.      The   black   areas   above 
and    below    the    patella    represent    the   steel    pins    viewed    nearly    from    the    ends. 


they  are  attacked.  One  of  the  most  common  and  distressing  errors 
of  judgment  is  dependent  on  the  failure  to  distinguish  between  static 
ulcers  due  to  common  varicose  veins  dependent  on  a  damming  back 
of  the  blood-stream  in  the  veins  incident  to  child-bearing  or  to  pro- 
longed standing  in  those  with  inherent  weakness  of  the  walls  of  the 


DISEASES   OF    THE   LOWER   EXTREMITIES 


497 


veins  of  the  legs,  and  those  due  to  a  preceding  obliterating  phlebitis 
affecting  the  deep  veins  in  the  leg.  The  one  is  cured,  the  other  made 
worse,  by  operation. 

CASE  1. — A  housewife  aged  fifty-four  came  to  the  hospital  be- 
cause of  an  ulcer  of  the  leg. 

History. — The   patient  has  had  an  ulcer   on  her  left   shin   for   a 
dozen  years.    At  first  it  healed  at  intervals  under  treatment,  but  for 


Fig.   256. — \'aricose  ulcei"  of  the   leg. 

the  past  six  years  it  has  been  constantly  open.  Two  years  ago  she 
had  an  erysipelas  of  the  leg  which  started  at  the  ulcer.  The  ulcer  is 
exceedingly  sensitive  to  touch  so  that  she  protects  it  with  an  oint- 
ment. She  has  had  nine  children  and  since  her  early  pregnancies 
she  has  had  dilated  veins  in  both  legs.  Her  general  health  has  been 
good. 

Examination. — She  is  a  large,  corpulent  woman,  apparently  in 
good  general  health.  The  long  saphenous  veins  are  dilated,  par- 
ticularly in  the  region  of  the  knees.  On  the  mesial  surface  of  the 
right  tibial  region  is  an  ulcer  1-1/2  x  2-1/2  inches.    The  borders  are 


498  CLINICAL   SURGERY   BY    CASE    HISTORIES 

cicatrized  and  dense  (Fig.  256).  The  floor  is  smooth  and  hard  and 
covered  by  small  excrescences.  The  borders  slightly  overhang  the 
base.  The  border  and  floor  of  the  ulcer  are  firmly  adherent  to  the 
bone  beneath.  The  floor  of  the  ulcer  was  exquisitely  sensitive  to 
manipulation. 

Diagnosis. — The  history  and  the  presence  of  varicose  veins  make 
the  diagnosis  easy.  The  border  is  smooth  and  glistening  and  dense 
elastic,  nothing  that  would  lead  me  to  suspect  malignancy.  The  type 
of  ulcer  is  evident  from  this  dense  border  and  the  smooth  glistening 
floor.    This  type  does  not  heal  by  any  treatment  save  excision. 

Treatment. — The  veins  were  resected  for  about  six  inches  below 
the  saphenous  opening,  and  a  spiral  nine  or  ten  inches  long  was  dis- 
sected out  below  the  knee.  The  entire  ulcer  was  then  resected  and 
the  defect  filled  with  a  Thiersch  graft. 

Pathology. — The  slides  showed  only  fibrous  tissue  in  which  were 
sparse,  thick-walled  vessels. 

After-course. — Keeovery  was  prompt  and  permanent.  The  pa- 
tient was  afterward  operated  on  for  procidentia. 

Comment. — Many  ulcers  in  this  region  may  be  cured  by  local  treat- 
ment. Once  the  border  becomes  thickened  and  the  floor  smooth  and 
glistening,  nothing  short  of  the  removal  of  the  ulcer  is  effective. 

CASE  2. — A  farmer  aged  twenty-eight  came  because  of  an  ulcer 
of  his  leg. 

History. — Two  years  ago  a  red  spot  appeared  on  his  leg  just  above 
the  ankle.  Within  a  month  an  ulcer  formed.  This  continued  to  en- 
large until  it  attained  its  present  size.  It  is  so  painful  at  times  that 
he  is  unable  to  work.  It  oozes  much  of  the  time,  which  when  it  dries, 
forms  a  scab,  and  this  increases  his  suffering.  Light  touch  is  usually" 
more  painful  than  heavy  pressure.  His  leg  swells  more  or  less,  es- 
pecially when  he  is  much  on  his  feet.  His  trouble  began  when  he 
had  typhoid  fever  ten  years  ago.  He  was  in  bed  ten  weeks.  He  had 
severe  pain  in  his  leg.  It  became  swollen  at  that  time,  and  remained 
so  for  many  weeks.  The  other  leg  is  not.  and  has  never  been  af- 
fected.   His  general  health  is  good. 

Examination. — The  leg  is  moderately  swelled  below  the  knee.  The 
veins  are  swelled  but  not  beaded  or  knotted.  The  opposite  leg  is  not 
aft'ected.  An  ulcer  5x3  cm.  is  located  on  the  mesial  surface  a  hand- 
breadth  above  his  ankle   (Fig.  257).     It  is  surrounded  by  a  hard, 


DISEASES    OF    THE   LOWER   EXTREMITIES 


499 


almost  cartilaginous  wall.  It  is  serrated  and  somewhat  undermined. 
The  base  of  the  ulcer  is  pale  red  and  shining,  almost  dry  except  at  the 
proximal  end,  where  a  clear,  thin  fluid  covers  it.  Fine  papilliform 
projections  protrude  from  the  surface,  especially  at  the  lower  part. 
It  is  these  projections  that  seem  most  sensitive  to  touch.  The  border 
is  but  little  sensitive. 

Diagnosis. — This  is  no  doubt  a  congestion  ulcer  caused  by  the  deep 
thrombosis  which  complicated  his  tj'phoid  fever.  That  it  is  so  is 
proved  by  the  fact  that  when  the  leg  is  emptied  of  blood  by  elevating 
it  and  then  compressing  the  long  saphenous  vein,  then  lowering  the 
leg  the  veins  refill  at  once.    The  fact  that  the  opposite  leg  is  unaffected 


-i 


1*™  '\i^^ 


Fig.    257. — Chronic   ulcer  of  the   leg  following  tj-phcid  fever   ten  j-ears  ago. 


also  suggests  a  unilateral  causation.  This  fact  makes  it  likely  that 
an  attempt  to  cure  the  ulcer  by  ligation  of  veins  as  is  done  in  the 
case  of  static  varicosities  would  result  only  in  destroying  the  remain- 
ing venous  return.  The  tendency  of  the  leg  to  swell  can  not  be  con- 
trolled by  operation.  His  chief  complaint  is  of  pain.  By  removing 
the  ulcer,  the  pain  will  be  removed  at  least  temporarily,  and  if  he 
will  lie  with  his  leg  elevated  two  weeks,  a  graft  will  heal  and  he  will 
be  temporarily  relieved  of  his  ulcer. 

Treatment. — The  ulcer  was  resected  by  an  oval  incision  and  the 
defect  covered  by  Thiersch  grafts. 

Pathology. — The  section  shows  a  pearly  white  gristly  surface.  The 
slide  shows  a  dense  rather  palely  staining  connective  tissue  with  some 
plasma  cell  infiltration. 


500  CLINICAL   SURGERY   BY    CASE    HISTORIES 

After-coiirse. — The  healing  was  prompt,  and  five  years  after,  the 
nicer  has  not  re-formed. 

Comment. — This  patient  has  done  uncommonly  well.  The  results 
are  usually  in  proportion  to  the  patient's  intelligence  and  willing- 
ness to  cooperate.  In  spite  of  all  caution  the  ulcer  maj^  return.  It 
would  be  desirable  if  he  could  change  his  occupation  to  a  less  labo- 
rious one,  though  he  is  better  off  in  one  requiring  locomotion  rather 
than  one  wliich  would  require  standing  without  movement. 

CASE  3. — A  fanner  aged  twenty-two  came  because  of  an  ulcerated 
leg. 

History. — He  has  had  swelling  of  his  left  leg  below  the  knee  for 
five  years.  Four  years  ago  he  was  operated  on  for  the  removal  of 
enlarged  veins.  Following  this  operation  the  leg  swelled  more  than 
before,  and  soon  an  ulcer  developed.  This  has  persisted  and  is  so 
painful  he  is  quite  incapacitated.  He  had  typhoid  fever  before  the 
development  of  the  swelling. 

Examination. — The  left  leg  below  the  knee  to  near  the  ankle  is  as 
large  as  the  leg  above  the  knee.  It  is  very  firm  and  can  not  be  made 
to  pit  save  about  the  ankle.  It  is  a  deep  bluish  red  in  color.  This  is 
most  marked  just  above  the  ankle.  At  this  point  there  is  an  ulcer 
the  size  of  a  watch.  The  ulcer  is  superficial  with  an  irregular  border 
with  small  secondarj-  ulcers  about  it.  These  also  are  very  super- 
ficial.    There  is  some  sensitiveness  about  the  ulcer. 

Diagnosis. — The  cause  of  the  disease  originally  is  a  typhoid  throm- 
bosis. This  was  aggravated  by  ill-advised  removal  of  the  superficial 
veins. 

Treatment. — -Amputation  was  advised  but  not  accepted. 

After-course. — A  year  later  the  condition  was  still  the  same. 

Comment. — In  viewing  the  dilated  superficial  veins  after  deep 
thrombosis  the  surgeon  should  heed  the  placard  advice  sometimes 
posted  over  the  fiddler  in  the  frontier  dance  halls  "Don't  shoot  the 
fiddler  he  is  doing  his  durndest."  The  return  flow  of  blood  will  not 
be  aided  by  removing  the  only  remaining  channels.  There  are  cases 
in  which  a  judicious  removal  of  veins,  in  these  cases  following  deep 
thrombosis,  may  be  done,  but  care  must  be  exercised  not  to  destroy 
the  main  channel. 


DISEASES    OF    THE    LOWER   EXTREMITIES 


501 


CASE  4. — A  woman  of  fifty-six  came  to  the  hospital  because  of 
ulcers  and  swelling  of  the  legs. 

History. — For  twelve  years  she  has  had  swelling  of  the  legs.     She 
has  been  troubled  for  the  most  of  this  time  with  an  ulcer  of  the  left 


Fig.  258. — Varicose   ulcers  of  the 


ankle.  The  swelling  is  less  intense  when  she  is  off  her  feet.  She  had 
a  double  milk  leg  following  her  fifth  confinement  twelve  years  ago. 
Her  physician  diagnosed  varicose  ulcersi  and  requests  that  she  be 
operated. 

Exaniinatio7i. — The  patient  is  a  large  woman  apparently  in  good 
general  health.     Her  thighs  are  disproportionately  large  even  to  her 


502  CLINICAL   SURGERY   BY    CASE    HISTORIES 

generous  trunk.  Over  the  lower  abdomen  and  thighs,  and  particn- 
larly  over  the  buttocks,  are  large  prominent  veins.  These  are  prom- 
inent when  the  patient  lies  down.  A  handbreadth  above  the  left 
ankle  is  an  ulcer  the  size  of  a  dollar  (Fig.  258) ,  The  walls  are  sharply 
defined  by  a  hard  heavy  scar.  Bordering  it  the  skin  shows  scarring 
and  the  skin  is  hard  and  fixed.  The  same  site  on  the  other  leg  is  oc- 
cupied by  a  similar  scar  but  there  is  no  ulcer.  Over  the  right  hip  is  a 
cicatricial  area  in  which  the  skin  is  firmly  attached  to  the  underlying 
tissue.  The  veins  are  less  prominent  over  this  area,  but  surrounding 
it  they  are  larger  than  elsewhere  in  this  neighborhood.  The  skin  of 
the  whole  lower  abdomen  and  thighs  is  thickened  and  the  underlying 
tissue  is  dense  and  elastic.  There  is  no  pitting  and  the  size  of  the 
veins  is  not  materially  influenced  by  the  change  in  position.  The 
general  examination  is  without  interest. 

Diagnosis. — The  condition  is  due  to  general  varicosities.  The  his- 
tory of  double  milk  leg  is  significant.  Because  the  veins  of  the  lower 
abdomen  are  involved  obliteration  at  least  as  high  as  the  external 
iliac  veins  must  have  taken  place.  The  fact  that  there  is  no  notable 
change  in  the  degree  of  filling  of  the  veins  on  the  change  of  position 
indicates  that  the  collateral  circulation  is  still  inadequate.  The 
degree  of  cicatricial  formation  about  the  ulcer  is  rather  surprising 
considering  the  degree  of  venous  stasis  and  indicates  a  less  degree  of 
actual  impairment  than  would  appear  from  inspection.  The  scarred 
area  over  the  right  hip  obviously  occurred  from  an  obliterating 
phlebitis  in  times  past.  The  physician's  diagnosis  is  correct,  but  his 
request  for  operation  must  be  interdicted. 

Treatment. — None. 

After-course — She  remains  the  same. 

Comment. — When  varicosities  are  due  to  the  obliteration  of  deep 
veins  of  the  leg,  removal  of  the  superficial  ones  but  takes  away  what 
little  there  remains  of  return  channels  and  the  condition  so  far  as  the 
disposition  to  ulceration  is  concerned  is  but  aggravated.  The  thick- 
ened subdermal  tissue  indicates  that  the  lymph  vessels  have  been  at 
least  partly  involved.  Usually  the  history  of  a  preceding  phlebitis  is 
sufficient  to  cause  one  to  suspect  this  variety  of  varicosity,  but  curi- 
ously enough  patients  seldom  volunteer  this  information.  If  the 
ulcer  is  out  of  proportion  to  the  extent  of  the  visible  vessels,  or  if  the 
subcutaneous  tissues  are  thickened,  and  to  a  less  degree  if  the  vessels 
are  palpable  rather  than  visible,  a  preceding  phlebitis  should  always 


DISEASES    OF    THE    LOWER   EXTREMITIES  503 

be  suspected.  Patients  who  can  give  as  much  time  as  necessary  and 
who  have  intelligence  enough  to  understand  the  difficulties  involved, 
may  be  operated  with  a  fair  hope  of  curing  the  ulcer.  The  prospects 
are  particularly  good  in  women  past  the  active  period  of  life  who  are 
content  to  spend  much  time  with  the  leg  supported  on  a  stool. 

CASE  5. — A  laborer  of  sixty  came  to  the  hospital  because  of  an 
ulcer  on  his  leg. 

History. — He  has  had  an  ulcer  on  his  leg  for  sixteen  years.  For 
a  number  of  years  before  that  time  he  had  trouble  with  an  ulcer,  but 
it  would  heal  at  intervals.  At  first  it  gradually  enlarged  but  now  for 
a  time  it  remained  stationary.  It  causes  some  pain  but  it  is  the  an- 
noyance of  the  dressing  chiefly  that  distresses  him. 

Examination. — He  has  varicosities  of  both  legs  and  eczema  of  the 
right.  On  the  left  leg  just  above  the  malleolus  is  an  ulcer  2  1/2  x  3 
inches  in  extent.  The  border  is  irregular  and  hard.  At  some  points 
there  is  an  effort  at  healing  while  at  others  the  disease  seems  to  be 
advancing  by  a  degeneration  at  the  border  of  small  circular  areas. 
Small  dots  are  seen  in  these  areas.  The  base  of  the  ulcer  is  covered 
with  dirty,  shiny,  grayish-white  granulations.  The  skin  about  the 
ulcer  is  atrophic  and  seems  adherent  to  the  deeper  structures.  The 
patient  has  fairly  good  health,  arteriosclerosis ;  a  blood  pressure  of 
180;  and  a  trace  of  albumin.,    (Fig.  259.) 

Diagnosis. — The  varicosities  of  the  leg  carrying  the  ulcer,  as  well 
as  of  the  other  one,  suggest  a  persistent  varicose  ulcer.  The  peculiar 
eating,  serrated  border  suggests  something  different.  The  small  whit- 
ish dots  suggest  epithelial  pearls.  The  name  Marjolin's  ulcer  has 
been  applied  to  this  condition  and  it  has  been  generally  subjected  to 
amputation. 

Treatment. — Amputation  4  inches  below  the  knee. 

Pathology. — A  cut  section  across  the  ulcer  shows  dense  fibrous 
tissues  without  evidence  of  epithelial  proliferation  at  the  border. 
The  slide  shows  proliferation  of  epithelium  and  some  changes  in  cell 
type.    There  is  no  definite  nest  formation. 

After-course. — There  has  been  no  recurrence. 

Comment. — The  malignant  features  of  this  disease  have  been  un- 
duly emphasized,  and  amputation  advised  on  the  strength  of  it. 
This,  my  first  case,  suj^plied  me  material  which  resulted  in  the  adop- 
tion of  a  conservative   policy.     A  wide   excision   followed  by   skin 


504  CLINICAL   SURGERY   BY    CASE    HISTORIES 


Fig.   259. — Marjolin's  ulcer   of  the   leg. 


DISEASES    OF    THE    LOWER   EXTREMITIES 


505 


grafting  results  in  a  permanent  cure.  In  selecting  the  line  of  inci- 
sion one  must  be  governed  by  the  state  of  the  skin  as  well  as  by  the 
border  of  the  ulcer.  A  skin  capable  of  supplying  a  good  circula- 
tion must  be  reached.  In  covering  the  defect,  if  -  a  base  with  a 
blood  suppl}^  is  reached,  Thiersch  grafts  may  be  used  as  after  the 
removal  of  a  simple  varicose  ulcer.  If  the  nutrition  does  not  seem 
ample,  a  sliding  graft  from  the  calf  of  the  leg  may  be  used  or  skin 
from  the  opposite  side  may  be  requisitioned. 

CASE  6. — A  dentist  aged  forty-two  consulted  me  because  of  a 
tumor  on  the  calf  of  the  leg. 

History. — For  a  number  of  j^ears  he  has  noticed  a  small  tumor  on 
the  calf  of  his  left  leg,  half  way  between  the  knee  and  ankle.  Re- 
cently it  has  annoyed  him  somewhat  because  of  the  rubbing  of  his 
trousers  against  it. 


"  ' ;  '•  i-  ■  -  ■•'     '  ii" 


A.  B. 

Fig.   260. — Bald-headed  sarcoma  of  the  calf.     A.  gross  appearance.     B.   Slide  of  the  same. 


506  CLINICAL    SURGERY    BY    CASE    HISTORIES 

Examination. — The  tumor  now  is  the  size  of  a  small  hickory  nut, 
(Fig.  260-^1)  spherical  in  form,  and  closely  attached  to  the  skin. 
The  surface  is  reddened,  giving  it  an  appearance  as  though  the  cover- 
ing were  mucous  membrane.  The  skin  is  not  movable  over  the  sur- 
face of  the  tumor. 

Diagnosis. — The  reddened  mucous  membrane-like  covering  stamps 
it  as  a  type  of  tumor  usually  seen  over  the  trunk  which  is  sometimes 
sarcomatous,   sometimes  epitheliomatous  in  histology. 

Treatment. — The  tumor  was  excised  with  a  1  cm.  margin  of  healthy 
skin  about  the  border  of  the  tumor  and  extending  down  to  the  fascia. 

Pathology. — The  cross  section  of  the  tumor  is  a  uniform  pale  pink 
color.  On  section  the  tumor  is  made  up  of  heavy  bundles  of  fibrous 
tissue  Avith  a  considerable  number  of  large  ovoid  cells  with  large 
ovoid  nuclei.     (Fig.  260-B.) 

After-course.— ^0  recurrence  has  taken  place. 

Comment. — The  known  clinical  fact  that  these  tumors  tend  to  re- 
turn has  more  to  do  with  arriving  at  a  diagnosis  of  fibrosarcoma  than 
the  histologic  appearance  of  the  tumor. 

CASE  7. — A  farmer  aged  forty-five  entered  the  hospital  because 
of  a  swelling-  of  his  left  knee. 

History. — The  patient  had  always  had  good  health  and  save  for 
the  present  illness  has  never  consulted  a  physician.  Two  years  be- 
fore he  had  complained  of  pain  in  the  region  of  the  left  knee,  and 
had  been  treated  for  rheumatism.  The  pain  continued,  however, 
especially  when  the  patient  was  walking.  There  was  very  little  pain 
when  he  sat  still.  For  several  months  he  had  used  a  cane  in  walking. 
About  four  months  before  entering  the  hospital  he  noticed  an  en- 
largement just  below  the  knee  joint  on  the  outside  of  the  leg.  This 
had  slowly  increased  until  it  was  about  half  the  size  of  an  egg.  The 
patient  thought  he  had  lost  some  weight.  There  was  no  history  of 
injury. 

Examination. — Just  below  the  left  knee  joint  on  the  outer  surface 
of  the  leg,  just  anterior  to  the  tibio-fibular  articulation  was  a  rather 
soft  tumor  mass  half  the  size  of  an  egg.  There  was  a  tendency  to 
bow-leg  on  the  left  side,  none  on  the  right.  Physical  examination 
otherwise  negative.  The  x-raj*  showed  destruction  of  a  considerable 
portion  of  the  upper  end  of  the  tibia  (Fig.  261).  Only  a  thin  plate 
of  bone  was  present  below  the  joint.     There  was  normal  bone  on  the 


DISEASES   OP    THE   LOWER   EXTREMITIES 


507 


inner  surface  of  the  tibia.  Urine  negative ;  hemoglobin  70  per  cent 
by  the  Tappqnist  scale,  white  blood  count  8,000,  temperature  98.2, 
pulse  72. 

Diagnosis. — A    slowly    growing    medullary    tumor    gradually    de- 


Fig.  261. — Sarcoma  of  the  head  of  the  tibia. 


508  CLINICAL   SURGERY   BY    CASE    HISTORIES 

stroying  the  surface  of  the  bone  could  liardly  be  other  than  a  sarcoma. 
Nearly  all  of  these  are  giant-celled  in  character. 

Treatment. — At  operation  the  tumor  mass  was  removed  and  the 
bone  thoroughh'  curetted,  care  being  taken  not  to  go  through  the  thin 
plate  of  bone  into  the  knee  joint.  The  cavity  was  then  packed  with 
gauze  and  the  incision  closed  except  at  one  point  for  drainage.  The 
patient  did  not  take  the  anesthetic  well,  and  showed  signs  of  shock 
after  the  operation,  but  was  in  good  condition  the  next  day.  He 
was  kept  in  bed  with  the  leg  splinted  for  twenty-four  days.  Then  the 
leg  was  put  in  a  cast,  and  he  was  allowed  to  go  home.  In  removing 
that  portion  nearest  the  joint,  the  thin  plate  of  bone  lying  beneath 
the  joint  cartilage  only  was  allowed  to  remain.  On  the  median  side 
of  the  tibia  also  only  a  thin  shell  of  bone  remained.  The  remainder 
of  the  shell  covering  the  tumor  was  removed.  After  the  operation 
was  completed,  there  remained  only  a  plate  of  bone  "L  "-shaped  to 
form  the  basis  of  the  new  bone.  The  amount  of  involvement  was 
much  greater  than  I  was  led  to  expect  from  the  study  of  the  x-ray 
plate. 

Pathologij. — The  material  removed  was  reddish  and  granular,  show- 
ing spicules  of  bone  about  the  border.  J\Iany  giant  cells  were  found 
on  microscopic  examination,  particularly  in  that  portion  of  the  tu- 
mor lying  nearest  the  bone. 

After-course. — He  returned  at  intervals  for  observation.  Koent- 
genograms  taken  at  these  times  showed  advancing  growth  of  bone. 
Up  to  the  present  time,  three  years  after  the  operation,  the  patient 
walks  without  a  limp  and  there  has  been  no  sign  of  recurrence. 

Comm-ent. — Nearly  all  of  these  cirt-umseribed  bone  tumors  are 
giant-celled  in  character  and  are  cured  readily  by  local  operations. 
Nearly,  but  not  all.  I  once  saw  inguinal  metastasis  in  a  patient  on 
whom  local  resection  had  been  done,  when  from  the  appearance  of 
the  x-ray  plate  it  seemed  a  permanent  cure  must  result.  AVhether  a 
resection,  not  a  curettage,  is  more  apt  to  be  followed  by  a  recurrence, 
I  do  not  know.  The  operation  was  done  by  a  competent  surgeon. 
In  cases,  such  as  the  one  recounted  here,  if  only  the  merest  shell  of 
bone  remains,  new  bone  will  form.  It  is  doubtful  whether  mere  loss 
of  bone  alone  can  form  an  excuse  for  amputation. 


DISEASES   OF    THE   LOWER   EXTREMITIES 


509 


CASE  8. — A  boy  was  brought  to  the  office  because  of  a  peculiar 
swelling  of  the  calf. 

History. — This  child  is  the  j^oungest  in  a  family  of  four,  the  other 
members  of  which  are  healthy  and  Avithout  blemish.  The  parents 
likewise  are  healthy.  The  father  relates  that  when  the  child  was  born 
the  cord  was  wrapped  about  its  left  leg.     It  was  noted  at  that 


Fig.   262-A. — Lymphangioma   of  the   calf. 


Fig.   262-B. — Cross  appearance  of  the  leg. 

time  that  the  calf  below  the  encircling  cord  was  somewhat  puffed. 
Nothing  more  was  noted  until  the  child  was  a  year  old  when 
it  was  observed  that  there  was  a  swelling  in  the  calf.  This  enlarged 
to  the  size  of  a  hen's  egg  in  three  weeks.  It  extended  upward  and 
downward  until  it  covered  the  posterior  surface  of  the  calf  muscles. 
When  the  child  was  fifteen  months  old  he  was  taken  to  a  surgeon 


510  ■  CLINICAL   SURGERY   BY    CASE    HISTORIES 

who  diagnosticated  a  lipoma  and  made  an  incision  to  remove  it. 
When  the  tumor  was  exposed,  lie  discovered  the  error  of  his  diagno- 
sis and  closed  the  incision.  It  is  now  five  months  since  this  event. 
During  this  time  the  tumor  has  grown  apace  with  the  child  but  prob- 
ably but  little  more.     He  seems  perfectly  well  otherwise. 

Examination. — The  boy  is  a  perfect  sample  of  a  boy  save  that  the 
calf  of  the  right  leg  is  augmented  by  a  tumor  mass  (Fig.  262- A).  It 
is  coextensive  with  the  bell}'  of  the  gastrocnemius  -muscle  and  at  first 
glance  reminds  one  of  a  pseudohypertrophic  muscular  dystrophy. 
On  palpation  the  mass  is  firm,  but  movable  on  the  muscle  beneath 
and  the  skin  is  not  freely  movable  over  it,  neither  is  the  skin  directly 
attached  to  the  tumor.  The  surface  of  the  tumor  is  firm,  slightly 
lobulated  as  though  tense  globules  had  been  submerged  in  a  mass  of 
equal  consistency.  It  was  incompressible  and  nonpulsating.  The 
leg  measures  141/^  inches  in  circumference  at  this  point.  The  nor- 
mal blood  vessels  could  be  felt  in  their  natural  situations. 

Diagnosis. — The  congenital  appearance,  the  close  relation  to  the 
fascia  of  the  calf  muscles,  the  tenseness  of  the  small  lobules  together 
with  the  incompressibility  stamp  it  as  a  cystic  lymphangioma. 

Treatment. — From  experience  with  cystic  lymphangiomas  of  the 
neck  it  was  assumed  that  the  x-ray  might  be  of  service.  Treatment 
was  given  by  a  competent  roentgenologist  at  intervals  for  a  period 
of  ten  months. 

After-course. — Soon  after  the  treatments  were  discontinued  the 
tumor  underwent  a  violent  reaction.  It  became  intensely  inflamed  so 
that  it  measured  22  inches  in  circumference.  It  was  hard  to  the 
touch.  The  child's  temperature  rose  to  103-105  and  remained  so 
for  many  weeks.  The  temperature  could  be  reduced  only  by  packing 
the  leg  in  ice.  The  child  was  stuporous  at  times.  The  fever  grad- 
ually subsided  at  the  end  of  seven  weeks  without  suppuration.  Fol- 
lowing this  the  leg  became  smaller  than  before  the  acute  inflamma- 
tion set  in.  Now  six  months  later  it  is  much  reduced  in  size.  It  is 
firm,  the  skin  is  more  intimately  attached  to  it  than  at  the  first  exami- 
nation and  the  small  bosselations  are  not  to  be  made  out.  On  the 
contrary,  the  whole  mass  feels  leathery  and  inelastic  and  the  skin  is 
attached  to  it.  Just  within  the  past  few  weeks  there  is  a  recrudes- 
cence of  the  inflammation  at  the  lower  pole  so  that  it  seems  hot  and 
manipulation  pains  the  child. 

Comment. — Evidently   this   mass   underwent   an   inflammatory   re- 


DISEASES   OF    THE   LOWER   EXTREMITIES  511 

action  as  is  commonly  observed  in  like  lesions  of  the  tongue.  For- 
tunately, unlike  the  lesions  of  the  tongue  which  increase  with  each 
exacerbation,  this  lesion  seems  to  have  been  markedly  reduced.  From 
the  character  of  the  process,  spontaneous  cure  is  not  likely,  and 
in  consequence  the  father  has  been  advised  that  the  growth  should 
be  removed  when  the  child  has  become  a  few  years  older  and  is  able 


Fig.  263-A. — Appearance  of  the   mass  after   excision. 


Fig.   263-B. — Cross    section   of   the   excised   mass. 

to  withstand  the  operation  better,  for  because  of  the  intimate  relation 
of  these  tumors  to  the  surrounding  growth  the  dissection  is  tedious 
and  time  consuming. 

Re-entrance. — Nine  months  after  the  above  was  written  the  child 
was  brought  back.  He  had  been  suffering  intense  pain  for  a  number  of 
months.  The  mass  was  smaller  than  when  last  observed  (Fig.  262-5). 
The  mass  was  dense  and  in  numerous  places  black  points  were  pro- 
truding from  the  skin,   presenting   the   aiDpearance   of   a   cutaneous 


512 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


hemorrhoid  when  being  shelled  out  through  a  small  incision.  It  was 
hoped  that  these  were  blood  clots  though  the  resemblance  to  melanotic 
masses  was  painfully  close  (Fig.  263-A).  Kemoval  of  the  mass  was 
advised  and  carried  out.  The  entire  affected  area  was  excised  and  the 
wound  packed.  Xo  attempt  was  made  to  cover  the  defect.  The 
tissue  removed  presented  a  lolnilated  pinkish  white  mass  with  blackish 
areas  between  (Fig.  263-5).  The  black  areas  proved  on  section  to  be 
blood  clots.  The  mass  of  the  tumor  was  made  up  of  large  mononu- 
clear cells  and  large  ovoid  nuclei.     These  occurred  in  long  chains 


Fig.   264. — Slide   of   lymphangioma   of   the   calf. 

and  were  for  the  most  part  separated  by  strands  of  connective  tis- 
sue (Fig.  264).  The  lad  died  six  months  later  of  exhaustion  due 
probably  to  visceral  metastasis. 

CASE  9. — A  bookkeeper  aged  twenty  cajne  to  the  hospital  because 
of  an  ulcer  on  his  ankle. 

History. — The  patient  has  always  had  good  health  until  October, 
two  years  ago,  when  he  began  to  have  a  sense  of  tightness  and 
pain  in  the  left  side  of  the  chest,  with  cough,  moderate  expectoration, 
fever  and  loss  of  weight.  He  was  in  bed  for  six  weeks.  During  Janu- 
ary and  February  he  had  night  sweats  and  in  ]\Iay  coughed  a  mod- 
erate hemorrhage.  After  this  he  began  to  improve.  During  March 
he  began  to  have  pain  in  his  left  ankle  with  swelling.     After  several 


DISEASES    OF    THE    LOWER   EXTREMITIES  513 

weeks  a  small  incision  was  made  into  the  swelling  by  his  physician, 
but  no  pus  was  found.  Following  this  there  was  a  spontaneous  opening 
in  several  other  places  and  the  site  of  the  incision  has  remained  open. 
Examination. — The  ankle  is  swollen,  particularly  about  the  external 
malleolus.  Just  over  this  point  are  three  ulcers.  They  vary  from  .5  to 
1.5  cm.  in  diameter  (Fig.  265).  Their  border  is  soft  and  under- 
mined, the  base  is  fine,  granular,  and  produces  but  little  pus.     None 


Fig.  265. — Tuberculosis  of  the  ankle. 

of  these  appear  to  communicate  with  the  joint.  The  ulcers  are 
sharply  defined,  somewhat  undermined,  and  the  floor  is  covered  with 
fine  granulations.  They  give  off  a  thin,  watery  discharge.  The  skin 
about  the  border  of  the  ulcer  is  a  deep  cyanotic  color.  The  movement 
of  the  ankle  is  limited  somewhat,  but  the  joint  surfaces  seem  unaf- 
fected. There  is  dullness  and  a  prolonged  expiratory  sound  in  the 
left  apex.  No  sputum  could  be  produced.  Laboratory  examination 
was  negative. 

Diagnosis. — The   patient   had   an   acutely   developing   lung   tuber- 


514  CLINICAL    SURGERY   BY    CASE    HISTORIES 

culosis  and  this  process  coming  on  during  its  height  at  once  suggests 
the  possibility  that  this  is  of  like  nature.  The  form  of  the  ulcer 
and  the  color  of  the  skin  bordering  them  appears  to  justify  this 
suspicion.  The  seat  of  the  infection  evidently  was  extracapsular 
or  at  least  extra-articular. 

Treatment.— The  lesions  were  treated  with  balsam  of  Peru  and 
the  joint  moderately  fixed  with  adhesive  strips. 

After-course. — Healing  was  complete  in  five  months  and  has  re- 
mained so. 

Comment. — The  recovery  of  the  lesion  would  no  doubt  have  been 
expedited  had  iodoform-glycerine  been  injected  into  the  tissues  about 
the  ulcer.  His  occupation  was  such  as  to  make  the  use  of  this  drug 
objectionable. 

CASE  10. — A  man  aged  forty-eight  came  because  of  a  small 
growth  on  his  leg. 

History. — The  trouble  has  been  present  for  twenty  years.  There 
is  a  small  nodule  on  the  outside  of  the  leg  below  the  knee.  He  has 
pain  in  the  foot. 

Examination. — A  tumor  the  size  of  an  olive  is  situated  in  the 
course  of  the  superficial  peroneal  nerve.  The  slightest  pressure 
causes  pain  in  the  foot.  It  has  gradually  increased  in  size  and  with 
this  an  increase  in  the  degree  of  pain. 

Diagnosis. — Because  pain  is  caused  in  the  region  of  the  distribu- 
tion of  the  superficial  peroneal  nerve  Avhen  the  tumor  is  pressed  on 
it  is  evident  that  the  growth  involves  this  nerve.  Alcohol  injections 
having  failed  to  give  relief,  and  the  pain  having  become  too  intense 
for  endurance,  removal  seems  to  be  indicated.  This  will  mean  a 
sensory  disturbance  on  the  outer  side  of  the  foot. 

Treatment. — The  nerve  and  tumor  were  exposed.  There  seemed 
to  be  no  Avay  of  removing  the  tumor  without  sacrificing  the  nerve, 
so  the  tumor  and  a  section  of  the  nerve  was  removed. 

Pathology. — The  gross  tumor  is  as  large  as  a  hickory  nut  (Fig. 
266-J.).  It  is  firm  to  the  touch  and  on  section  shows  a  pinkish- 
white,  glistening  surface.  The  slide  shows  mostly  fibrous  tissue 
with  but  little  cellular  increase  (Fig.  266-B). 

After-course. — A  year  after  the  operation  the  patient  writes  that 
he  has  been  free  from  pain  since  the  operation.  There  is  some  numb- 
ness on  the  outer  side  of  the  foot.    This  he  regards  with  satisfaction 


DISEASES    OF    THE   LOWER   EXTREMITIES 


515 


because  it  reminds  him  of  the  relief  he  has  from  the  long-continued 
pain. 

Comnient.~The  destruction  of  a  cutaneous  nerve  supplying  the 
hand  is  a  matter  of  some  moment.     For  this  reason  I  feared  to  re- 


Fig.  2.66-A. — Xeuroiibroma  of  the   superncial  peroneal  nerve. 


Fig.    266-1?. —  Slide   of   the    preceding,    made   up    of    fibrous   tissue   with   some   connective   tissue 
cells   but  v^rithout   nerve   or   malignant  elements. 


516 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


move  the  tumor  surroiindino-  the  peroneal  nerve, 
least,  the  results  Avere  satisfactorv. 


In  this  case,  at 


CASE  11. — A  student  aged  eighteen  came  because  of  a  stiff  ankle 
and  a  scar  on  the  posterior  surface  of  his  right  leg. 

History. — Two  years  ago  he  was  on  a  bob  sled  which  hit  a  Ford 
and  he  suffered  a  broken  right  femur  and  bruised  the  calf  of  his 


Fig    267. — "\'olkmann"s   contraction"   of   the   calf   muscles. 


DISEASES    OF    THE    LOWER    EXTRE:*nTIES  517 

right  leg.  He  wore  a  splint,  and  a  weight  was  applied.  In  five 
weeks  the  dressings  were  removed  and  it  was  found  that  abscesses 
were  forming  in  several  places.  Xine  openings  had  to  be  made  be- 
fore healing  finally  took  place.  Small  sinuses  persisted  for  more 
than  a  year.  The  little  toe  became  infiltrated  and  was  removed. 
After  healing  was  complete  it  was  found  that  the  ankle  was  stiff' 
and  the  toes  pointed  downwards. 

Examination. — The  foot  is  extended  (Fig.  267).  but  there  is  no 
bony  ankylosis,  dorsal  flexion  being  due  to  the  shortening  of  the  ten- 
don. A  deep  scar  occupies  the  middle  of  the  lateral  side  of  the 
calf.  Smaller  sears  are  on  the  medial  side  and  about  the  tendon 
near  the  ankle.  The  calf  muscles  are  firm  and  sear-like.  The  skin 
is  inelastic  and  is  intimately  attached  to  the  skin,  particularly  near 
the  ankle. 

Diagnosis. — Obviously  there  was  an  inflammation  involving  the 
muscles  vrhich  resulted  in  suppuration.  A  fibrosis  has  resulted 
which  has  destroyed  the  contraction  powers  of  the  muscles.  The 
lengthening  of  the  tendon,  therefore,  cannot  restore  function  and 
all  that  can  be  done  is  to  provide  a  better  position  of  the  foot. 

Treatment. — The  tendon  was  lengthened  by  plastic.  The  head  of 
the  astragalus  was  removed.  In  forcing  the  foot  to  a  right  angle 
the  skin  above  the  ankle  ruptured  because  of  its  inelasticity  and 
contracted  state.     The  foot  was  held  at  right  angles  with  a  splint. 

After-course. — Some  flexibility  in  the  ankle  remained  but  no  vol- 
untary motion  was  restored.  The  spring  in  the  ankle  resembles  that 
in  the  ankle  of  an  artificial  leg. 

Comment. — Suppuration  is  not  ustially  a  concomitant  of  Yolk- 
mann's  contraction.  The  mtiscle  changes  and  the  history  of  tight 
bandaging  warrants  the  phicing  of  the  case  in  this  category.  Once 
a  fibrosing  myositis  has  taken  place,  restoration  of  function  is  not 
possible. 

DISEASES  OF  THE  FOOT 

C4angrenous  affections  of  the  foot  are  common.  Wide  early  ampu- 
tation is  important.  Chromatophoric  tumors  must  always  be  sus- 
pected when  there  is  a  tumor  or  ulcerous  lesion.  The  painful  affec- 
tions mav  be  either  inflammatorv  or  static,  or  both. 


518 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


CASE  1. — A  man  aged  seventy-six  came  because  of  blackening 
and  of  pain  in  the  right  foot. 

Hisfuri/. — Two  months  aji'o  he  began  to  haYe  pain  in  his  right  foot. 
He  noted  tliat  it  had  a  numb  feelino:  despite  the  pain.     A  month  ago 


Fig.   268. — Diffuse   dry  gangrene  of  the  foot. 


DISEASES    OF    THE   LOAVER    EXTREMITIES  519 

he  noted  that  a  black  area  had  formed  about  the  nail  of  the  great  toe 
and  above  the  ankle.  Following  this,  the  other  toes  became  black 
and  the  lateral  border  of  the  sole  as  well.  Because  of  the  pain,  he 
has  been  obliged  to  remain  in  bed.     His  appetite  is  indifferent. 

Examination. — The  blackened  portions  of  the  foot  (Fig.  268)  are 
hard  to  the  touch.  The  remaining  part  of  the  foot  has  a  peculiar 
soft  feel.  The  black  area  extends  in  addition  to  the  areas  above 
noted,  along  the  tibial  crest  to  near  the  knee.  He  complains  bitterly 
when  the  foot  is  moved  in  the  slightest  degree.  No  pulsation  can 
be  made  out  below  Scarpa's  triangle.  The  patient  presents  a  gen- 
eral arterial  sclerosis  with  a  blood  pressure  of  190. 

Diagnosis. — The  slow  onset  and  the  dried  state  of  the  extremity 
align  this  case  with  the  senile  gangrene. 

Treatment. — Amputation  at  the  junction  of  the  lower  and  middle 
thirds  of  the  thigh  was  done  under  spinal  anesthesia. 

Pathology. — The  vessels  were  much  thickened  and  calcareous,  par- 
ticularly in  the  popliteal  space.  A  thrombus  extended  from  this 
to  far  down  the  tibial  and  popliteal  arteries.  There  was  no  bleed- 
ing from  the  articular  vessels  during  the  course  of  the  operation. 

After-course. — The  patient  promptly  recovered  his  appetite  and 
general  strength.  There  was  some  disturbance  in  the  wound  healing 
because  of  necrosis  of  one  corner  of  the  flap. 

Cormnent. — The  fact  that  the  progress  was  fairly  rapid  and  the 
area  of  changed  nutrition  widely  distributed  made  it  imperative  that 
the  amputation  be  done  high  up.  The  fact  that  one  corner  of  a  flap 
became  gangrenous  following  operation  indicated  that  the  opera- 
tion was  done  at  the  very  lowest  possible  limit. 

CASE  2. — A  man  aged  seventy-tw^o  came  to  the  hospital  because 
of  a  g-eneral  blackening-  of  the  toes  of  the  right  foot. 

History. — For  some  years  the  patient  has  had  pain  in  the  feet,  par- 
ticularly in  the  soles.  These  pains  were  not  continuous.  Recently 
he  noted  that  this  pain  was  more  severe  and  predominately  in  the 
right  foot.  Ten  weeks  ago  the  great  toe  began  to  blacken.  This  has 
gradually  spread  until  now  it  extends  up  half  the  distance  to  the 
ankle.     There  is  now  a  general  soreness  but  the  pain  is  less. 

Examination. — From  the  tarsometatarsal  region  distal  ward  the 
foot  is  coal  black,  dense  and  dry  (Fig.  269).  The  line  of  demarca- 
tion between  the  black  area  and  the  unaffected  area  is  very  sharply 


520 


CLINICAL    PFRGERY   BY    CASE    HISTORIES 


defined.  The  skin  on  the  proximal  side  shows  a  slight  reaction  as 
if  an  attempt  were  being  made  to  cast  off  the  dead  portion.  The 
patient  has  a  pronounced  arteriosclerosis,  a  moderate  prostatic  en- 
largement, and  abundant  urine  of  low  specific  gravity. 

Diagnosis. — The  sharp  line  of  demarcation  indicates  a  localized  vas- 
cular disturbance.  This  makes  amj^utation  possible  at  a  lower  line 
than  would  be  the  case  if  the  gangrene  were  patchy  as  in  the  preced- 


Fig.  269. — Localized  dry  gangrene  of  the  foot. 


ing  case.  There  is  no  excuse,  however,  for  amputating  lower  than 
the  junction  of  the  upper  and  middle  thirds  of  the  calf. 

Treatment. — Amputation  under  spinal  anesthesia  was  done  four 
inches  below  the  knee. 

Pathology. — The  popliteal  and  tibial  vessels  were  occluded  with 
a  clot  but  the  articular  vessels  were  free  as  were  the  muscular.  There 
was  marked  thickening  of  the  plantar  vessels. 

Comment. — The  prodromal  pains  were  long  drawn  out  and  during 
this  period  the  use  of  Ringer's  solution  might  have  averted  the  major 
disturbance.  The  fact  that  the  disturbance  of  nutrition  advanced 
so   slowly   and  particularly  because   the    line    of   demarcation   was 


DISEASES    OF    THE    LOWER    EXTRE:MITIES  521 

sharp  it  was  eyident  that  the  nutritional  disturbance  was  loeah  This 
admitted  of  a  lower  amputation  than  would  have  been  the  case  had 
the  demarcation  been  less  sharp. 

CASE  3. — The  patient  suffers  from  mental  aberration,  swelling, 
and  blackening-  of  the  foot. 

History. — Age  sixty-four.  While  prospecting-  in  the  hills  the  pa- 
tient evidentlv  lost  his  way.  So  far  as  can  be  determined  he  was 
without  food  for  several  days,  when  found  he  was  unable  to  account 
for  his  whereabouts.  It  is  not  possible  to  state  whether  he  lost  his 
way  and  became  delirious  from  exposure  or  whether  he  became  de- 
lirious and  because  of  this  lost  his  way. 

Examination. — The  patient  is  unable  to  lie  down  because  of  dysp- 
nea. His  apex  is  bounding  and  diffuse,  displaced  three  finger- 
breadths  downward  and  outward.  The  rate  is  about  90  and  inter- 
mittent. There  is  some  dullness  at  the  bases  of  both  lungs  with 
moist  small  and  medium-sized  rales  throughout  the  lungs.  Both 
feet  are  swollen.  The  right  is  black  and  the  skin  has  separated  over 
wide  areas  (Fig.  270).  Fluid  oozes  from  the  areas  so  exposed.  Ma- 
nipulation of  the  leg  seems  to  cause  but  little  discomfort. 

Diagnosis. — It  is  not  possible  to  state  whether  the  condition  was 
due  primarily  to  exposure  or  to  vessel  occlusion.  The  fact  that  the 
other  foot  is  equally  swollen  but  not  gangrenous  gives  warranty  to 
the  supposition  that  had  he  not  been  subject  to  the  exposure  he 
would  not  have  had  gangrene.  The  affected  part  is  moist  for  the 
most  part,  but  the  toes  are  beginning  to  mummify  which  indicates 
the  difference  in  the  condition  is  due  to  the  rapidity  of  the  onset 
and  not  because  of  a  difference  in  the  nature  of  the  process.  This 
removes  it  from  the  class  of  the  moist  gangrene,  synonymous  with 
infection. 

Treatment. — Amputation  in  the  midthigh  under  spinal  anesthesia. 
Because  of  the  dyspnea  the  amputation  had  to  be  done  with  the  pa- 
tient in  the  sitting  position.  The  flaps  were  held  in  position  by  two 
loose  silkworm-gut  sutures  and  the  remainder  of  the  wound  packed 
with  gauze.     He  was  given  tr.  strophanthus. 

Pathology. — Both  veins  and  arteries  were  filled  with  blood  clots 
as  high  as  the  upper  border  of  the  popliteal  space.  The  tissue  was 
edematous  and  infiltrated  with  a  bloody  fluid.  The  tissues  about  the 
toe  nails  were  beginning  to  mummifv. 


noo 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


i'ig.   27'.). — kajjidly   dcvelojang   ai 


V   saiiKi'Lin 


of   the  foot. 


DISEASES    OF    THE    LOWER   EXTREMITIES  523 

After-course. — The  wound  healed  promptly  and  the  dyspnea  and 
cardiac  dilatation  subsided,  and  a  year  later  the  patient  seemed  in 
good  health. 

Comment. — He  has  no  memory  of  the  last  days  of  his  wandering, 
but  obviously  he  was  lost  and  his  subsequent  disturbances  were  the 
result  of  exj)osure.  The  cardiac  and  associated  lung  condition  also 
were  due  to  exposure.  The  fact  that  his  feet  had  been  wet  and  cold 
accounts  for  the  deep  changes  with  associated  vascular  changes,  though 
the  feet  at  no  time  were  actually  frozen.  This  conclusion  seems 
warranted,  since  now  three  years  after,  he  is  fully  recovered.  Neither 
the  heart,  lungs,  nor  remaining  foot  gives  any  evidence  of  the  past 
serious  condition.  In  this  case  spinal  anesthesia  was  extremely  val- 
uable. A  general  anesthesia  was  quite  out  of  the  question  and  in  a 
leg  in  the  state  of  this  one,  local  anesthesia  would  have  been  extremely 
difficult. 

CASE  4. — A  housewife  aged  sixty-one  was  brought  to  the  hospital 
because  of  dyspnea,  a  distended  abdomen,  and  pain  in  the  side  and 
back. 

History. — The  patient  was  not  rational,  due,  a  daughter  stated,  to  a 
tablet  given  by  the  local  doctor  in  order  to  make  it  possible  to  move 
her  to  the  hospital.     The  following  history  was  given  by  a  daughter : 

She  has  had  shortness  of  breath  and  weakness  at  intervals  for  a 
number  of  years.  She  has  had  more  or  less  chronic  cough.  Swell- 
ing of  the  feet  noticed  six  months  ago.  Since  two  weeks  she  has  had 
swelling  of  the  abdomen  and  pain  in  the  right  side  and  back.  Past 
illnesses  not  known.  Has  had  eight  children,  seven  births.  No  mis- 
carriages. One  child  died  at  one  month,  cause  unknown,  one  at 
nineteen  years  of  typhoid. 

Examination. — The  patient  is  sitting  up  in  bed,  threshing  the 
arms  about,  and  talking  very  irrationally.  She  continually  rubs  her 
nose.  The  skin  all  over  the  body  pits  on  pressure.  The  face  is  cy- 
anosed  and  the  breathing  rapid.  The  pupils  are  moderately  dilated. 
There  is  a  wide  area  of  pulsation  over  the  chest  wall,  but  the  apex 
beat  is  not  discernible.  The  heart  is  rapid,  about  170  per  minute 
and  arrhythmic.  The  area  of  dullness  extends  to  the  axillary  line. 
No  murmur  could  be  made  out. 

The  bases  of  the  lungs  are  dull  with  crepitant  rales  on  both  sides. 
Abdomen  verv  much  distended  with  dullness  in  both  flanks.     Liver 


524  CLINICAL    SURGERY    BY    CASE    HISTORIES 

margin  can  not  he  made  out  but  there  is  marked  tenderness  in  the 
upper  right  (luadrant.  The  pulse  is  as  given.  170,  the  respiration  30, 
the  temperature  101.  The  urine  is  1.010.  albumin  a  trace  and  a  few 
hyaline  easts. 

Diagnosis. — The  patient  evidently  has  a  marked  myocardial  de- 
compensation. Its  exact  duration  could  not  be  learned  from  her  com- 
panion. The  ])ain  in  the  abdomen  is  of  rdativt^ly  recent  date.  It  is 
not  possil)le  to  establish  the  coincidence  of  the  decompensation  with 
the  advent  of  the  upper  abdominal  pain.  Because  of  the  state  of 
the  patient  an  accurate  state  of  the  liver  and  abdominal  wall  cDuld 
not  be  determined.  There  was  free  tluid  in  tln"  lower  abdomen,  how- 
ever, decompensation  is  probably  the  cause  oi  the  pain  in  the  right 
upper  quadrant.  At  any  rate,  a  conservative  plan  is  the  only  one 
possible. 

Treatment. — She  was  given  digitalin. 

After-course. — For  a  few  days  following  the  temperature  varied 
between  96°  and  100.5°,  the  respiration  30  to  34:  and  the  pulse  was 
uncountable  for  the  most  part.  At  the  end  of  the  week  the  tempera- 
ture varied  98°  to  99°.  the  pulse  92  to  120  and  the  respiration  22  to 
28.  She  was  quite  rational  and  fairly  comfortable.  Suddenly  she 
complained  of  great  pain  in  the  right  foot  and  leg.  Wlien  this  ex- 
tremity was  examined  it  was  cold  and  bluish.  The  femoral  artery 
pulsated  vigorously,  but  the  popliteal  and  those  below  could  not  be 
discovered.  Obviously  there  was  thrombosis  of  the  popliteal  artery. 
On  the  fourth  day  the  end  of  the  big  toe  began  to  become  dry  and 
blue-black  spots  appeared  on  the  instep  and  above  the  ankle.  On 
the  eighth  day  the  foot  had  become  quite  black  and  mottling  appeared 
above  the  ankle.  The  pain  was  still  severe.  The  temperature  at 
the  time  the  embolism  occurred  dropped  to  96  -  and  for  ten  days 
following  varied  from  f)7'  to  101.5°.  The  pulse  remained  around 
90.  At  this  time  the  albumin  was  much  increased  and  there  were 
many  casts,  but  the  specific  gravity  was  1.020. 

Thirty-three  days  after  the  onset  of  the  embolism,  demarcation 
was  complete.  Amputation  of  the  leg  was  done  under  spinal  anes- 
thesia with  the  following  technic :  One  tablet  of  novocain  containing 
214  grains  was  sterilized  in  3  c.c.  of  water.  At  the  time  of  use  4  drops 
of  adrenalin  were  added  from  the  bottle  and  the  whole  injected  into 
the  spinal  canal,  after  withdrawing  3  c.c.  of  the  spinal  fluid.  In 
order  to  make  the  shock  as  little  as  possible  I  started  to  amputate 


DISEASES    OF    THE    LOWER    EXTREMITIES  525 

below  the  knee,  but  finding  the  blood  vessels  thrombosed,  amputation 
was  done  above  the  knee.  There  was  no  shock,  and  no  pain.  In 
fact  the  patient  did  not  know  the  amputation  had  been  done.  Fol- 
lowing this,  improvement  was  rapid  and  compensation  was  restored 
in  large  measure. 

Comment. — This  was  one  of  my  first  cases  of  amputating  for  gan- 
grene under  spinal  anesthesia.  Now  I  should  not  wait  for  demarca- 
tion in  the  hope  of  being  able  to  amputate  below  the  knee  but  would 
amputate  at  once  above  the  knee.  In  the  management  of  these  cases 
the  spinal  anesthesia  has  solved  the  question  of  shock.  I  have  re- 
peatedly amjDutated  when  the  patient  was  so  dyspneic  she  could  not 
lie  down.  When  gangrene  begins,  if  from  thrombosis,  after  the  im- 
mediate shock  subsides,  the  sooner  the  amputation  is  done  the  bet- 
ter. The  retention  of  a  necrosing  protein  can  but  jeopardize  a  heav- 
ily burdened  patient. 

CASE  4-A. — A  boy  aged  seven  was  brought  to  the  hospital  be- 
cause of  a  swelling  of  his  ankle. 

History. — For  more  than  a  year  the  mother  has  noticed  that  the 
inner  side  of  the  ankle  was  enlarging.  It  has  continued  gradually 
to  enlarge  to  the  present  time.  The  lad  has  had  no  discomfort  from 
it.    His  health  has  always  been  good. 

Examination. — The  site  of  the  internal  malleolus  is  occupied  by  a 
prominence  the  size  of  half  an  egg.  The  skin  over  it  is  not  discol- 
ored. It  is  hard  to  the  touch  and  is  not  sensitive  to  pressure.  The 
lower  half  moves  with  flexion  of  the  foot  while  the  upper  does  not. 
The  x-ray  shows  an  outgrowth  on  the  outer  malleolus  and  from  the 
astragalus.  The  masses  show  trabeculations  similar  to  that  of  the 
bone  from  which  they  spring,  but  the  trabecule  are  larger  (Fig. 
271-A). 

Diagnosis.— The  mottled  appearance  of  the  x-ray  suggests  some 
bony  outgrowth  without  any  cartilaginous  admixture.  Since  some 
of  these  groAvths  manifest  malignancy,  their  removal  is  indicated. 

Treatment.— The  upper  half  of  the  astragalus  and  the  tibia  below 
the  epiphyseal  line  were  removed. 

PatJwIogij. — The  growth  is  porous  osteoma.  Xo  cartilaginous  ele- 
ments can  be  found. 

After-course. — The  wound  healed  without  incident,  and  locomo- 
tion became  unhindered.     Now  for  four  years  after  operation  there 


526 


CLINICAL    SURGERY    BY    CASE    HISTORIES 


is  inversion  of  the  foot  due  to  eloiiiiation  of  the  fibula,  while  the 
tibia  remains  stationary.  To  correct  this  it  will  be  necessary  to  re- 
duce the  outer  border  of  Avhat  remains  of  the  astragalus. 

Conimfut. — These  osteomas  of  the  tarsal  bones  usually  respoiul  to 
local  resection.  I  believe  it  would  have  been  proper  to  have 
removed  the  liyperostosis  from  tlie  astrag-alus,  only  leaving  the 
epiphyseal   end  of  the  til)ia.     Tliis  would  have  prevented  the  now 


Fig.    27]-A. — Chondroma   of   the   astragalus. 


DISEASES    OF    THE   LOWER   EXTREMITIES  527 

annoying  shortening  of  that  bone.  Tlie  irritation  manifest  in  tlie 
tibia  probably  was  due  to  the  irritation  from  the  growth  in  the 
astragalus.  The  preconceived  notion  that  it  might  contain  carti- 
lage proved  to  be  erroneous.  Past  mistakes  sometimes  leave  a  sub- 
stratum of  caution  that  cause  us  to  make  others  of  an  opposite 
character. 

CASE  4-B. — A  housewife  of  thirty  came  because  of  a  club  foot 
with  swelling'  and  pain  when  walking. 

History. — The  foot  gave  little  trouble  up  to  ten  years  ago.  AVhile 
she  was  pregnant  with  her  first  child  the  foot  began  to  pain.  It 
would  swell  up  towards  evening  and  hurt  a  great  deal,  but  she  did 
nothing  for  it  and  it  was  always  better  the  next  morning.  In  De- 
cember, 1918,  she  had  an  attack  of  influenza  and  since  that  time 
there  has  been  such  a  continuous  pain  in  the  foot  that  she  could 
hardly  walk.    Her  general  health  is  good. 

Examination. — The  left  foot  is  clubbed.  There  is  a  large  cyst-like 
mass  on  the  dependent  outer  border  of  the  foot  (Fig.  211-B).  It  is 
spherical  with  a  firm  wall.  It  is  not  painful  to  pressure.  The  x-ray 
shows  the  usual  picture  of  an  extreme  equino-varus.  The  cyst  wall 
casts  a  dark  shadow  (Fig.  271-C). 

Diagnosis. — Because  of  the  marked  deformity  and  the  persistence 
of  the  mass  amputation  seems  better  than  any  attempt  to  restore 
the  normal  outlines  of  the  foot.  The  mass  beneath  seems  to  be  but 
a  large  bursa  with  dense  walls. 

Treatment. — The  foot  was  amputated  just  above  the  ankle  joint. 

PatJioIogij. — The  cyst  was  filled  with  a  clear  fluid.  The  wall  was 
very  dense  and  fibrous,  but  no  calcareous  matter  was  demonstrated 
to  account  for  the  dark  shadow  on  the  x-ray  picture. 

After-course. — The  wound  healed  by  primary  union.  There  was 
considerable  serous  fluid  oozed  from  the  wound  and  this  was  still 
present  at  the  time  the  patient  was  alloAved  to  go  home.  The  skin 
was  under  considerable  tension  so  the  sutures  were  allowed  to  re- 
main. The  patient  insisted  on  going  home  nine  clays  after  operation, 
against  advice.  She  was  allowed  to  go  Avithout  removing  the  su- 
tures, under  promise  to  come  back  in  five  days  for  examination.  The 
wound  was  healing  well  at  this  time.  Later  she  returned  with  a 
large  ulcer  on  the  end  of  the  stump.  No  local  cause  was  apparent 
and  a  testing  of  the  sensation  showed  it  to  be  markedly  diminished. 


)28 


CLINICAL   SURGERY   BY    CASE    HISTORIES 


Fig.  271-B. — C^'st  coniijlicating  a  club  foot. 


Fig.   271-C. — Calcareous  deposit  in  the   wall  of  the  preceding. 


DISEASES    OF    THE    LOWER    EXTREMITIES 


529 


Examination  of  the  sacral  region  showed  a  soft  fatty  tumor.     Re- 
amputation  was  done  five  inches  below  the  knee. 

Comment. — The  amputation  was  made  in  the  wrong  place.  The 
artificial  limb  makers  like  them  done  about  five  inches  below  the 
tuberosity  of  the  tibia.  The  long  stump  left  in  this  case  interferes 
with  the  construction  of  the  ankle.  A  unilateral  foot  deformity  or 
one  of  any  unusual  degree  calls  for  the  search  for  an  occult  spina 
bifida.  Possibly  the  presence  of  this  deformity  was  responsible  for 
the  disturbance  of  the  foot  during  pregnancy.  Xo  mass  could  be 
felt  in  the  pelvis,  however. 

CASE  5. — A  farmer  aged  twenty  came  to  the  hospital  because  of 
a  swelling  over  his  ankle  joint. 

History. — For  a  year  he  had  noticed  a  swelling  over  his  ankle  joint. 
It  caused  him  but  little  trouble  but  recently  it  has  developed  more 


Fig.  272. — Bursitis  peroneus  tendon. 

rapidly  and  he  has  had  some  pain.     His  general  health  has  always 
been  excellent. 

Examination. — Anterior  to  and  just  below  the  external  malleolus 
of  his   left   foot   is   a   soft   fluctuating   swelling    (Fig.   272).      It   is 


530  CLINICAL    SURCKRY    BY    CASE    HISTORIES 

not  painful,  and  does  not  seem  to  communicate  with  the  ankle  joint. 
The  movements  of  the  foot  are  not  impaired.  No  dense  bodies  can 
be  felt  in  it. 

Diagnosis. — ^Its  soft  fluctuating-  feel  distinguishes  it  from  a  gan- 
glion and  the  absence  of  rice  bodies  excludes  it  from  tuberculosis.  It 
must  be,  therefore,  a  hydrops  of  the  peroneal  tendon. 

Treatment. — The  sac  was  dissected  out  and  in  the  process  the  pero- 
neal tendons  were  exposed  for  a  distance  of  two  inches. 

Pathology. — The  tissue  removed  was  a  simple  synovial  sac  without 
thickening  of  any  sort. 

After-course. — Motion  was  unimpaired  after  a  month. 

Comment. — These  conditions  must  be  operated  on  with  the  most 
careful  attention  to  detail  both  as  to  asepsis  and  teehnic  or  impaired 
function  will  result.  Tliey  are  not  suited  for  office  or  dispensary 
practice. 

CASE  6. — A  housewife  aged  thirty-six  came  to  me  because  of  a 
sore  toe. 

Historij. — Xine  months  ago  she  notic;'d  a  low  ])iniple  on  the  inside 
of  her  right  toe.  It  did  not  pain  mueli  but  slie  regarded  it  as  a  soft 
corn.  As  it  began  to  develop  more  rapidly,  exceeding  the  confines 
of  a  corn,  her  physician  sent  her  to  a  dermatologist  who  treat  t1  her 
with  injections  and  later  with  radium.  Since  this  did  not  slow  up  the 
disease,  she  was  advised  to  see  a  surgeon. 

Examination. — On  the  lateral  side  of  the  left  great  toe  is  a  flat  mass, 
%  inches  across.  It  is  a  mottled  grayish  wliite  and  red.  It  is  low 
fungoid  in  outline  and  gives  the  appearance  of  pushing  out  through 
the  skin  (P^'ig.  273-^).  The  bordering  skin  is  rolled  out  and  does  not 
appear  to  be  connected  with  the  tumor.  The  trilnitary  lymph  ap- 
paratus is  free.     Her  general  health  is  good. 

Diagnosis. — The  mottled  appearance  of  the  tumor  and  its  inde- 
pendence of  the  skin  stamp  it  as  a  melanosarcoma  or  a  giant-celled 
sarcoma  of  the  tendon  sheath.  The  latter  is  unlikely,  since  the  sar- 
comas do  not  ulcerate  unless  molested.  How  much  the  efforts  of 
the  dermatologist  may  have  contributed  to  this  end  can  not  be  de- 
termined. The  patient's  early  diagnosis  of  a  corn  would  seem  to 
count  against  such  possibility.  The  previous  diagnosis  of  syphilis  is 
untenable  since  the  trouble  is  evidently  a  proliferative  one,  the  skin  be- 
ing destroved  bv  the  growth  of  the  mass.     An  amelanotic  melanoma 


DISEASES    OF    THE    LOT^-ER    EXTREMITIES 


531 


seems,  therefore,  to  be  the  only  diagnosis  possible.  If  the  above 
conclusion  is  correct,  no  treatment  will  be  of  avail. 

Treatment. — X  metatarso-phalangeal  amputation  was  done. 

Pathology. — The  tumor  is  a  fungoid  mass  vrliich  on  section  shows 
a  mottled  appearance.     The  slide  shows  large  ovoid  cells  in  columns 


Fig.  27o-A. — ^lelanoblastoma  of  the  great  toe. 


independent  of  the  epidermal  epithelium  intermingled  with  fibrous 
tissue  (Fig.  273-5). 

After-cours.e. — The  patient  returned  in  three  months  with  numer- 
ous small  tumors  scattered  over  the  dorsum  of  the  foot  and  the  in- 
guinal lymphatics  were  enlarged.  In  the  succeeding  months  aU.  these 
extended  and  masses  appeared  in  the  abdomen  which  increased  until 
she  died. 

Comment. — Possibly  an  earlier  amputation  would  have  prevented 
these  recurrences  on  the  dorsum  of  the  foot.     Logic  would  seem  to 


532 


CLINICAL    PUROERY    BY    CASE    HISTORIES 


favor  such  a  conclusion,  but   experience  fails  to  find  facts  to  sub- 
stantiate it. 

CASE  7. — A  man  aged  sixty-four  was  sent  to  me  because  of  an 
ulcer  below  his  ankle. 

History. — For  several  years  he  lias  had  an  ulcer  below  his  left 
ankle.  It  began  as  a  small  irregular  ulcer  and  gradually  extended 
around  the  edge.     It  has  gradually  enlarged.     It  has  caused  no  pain 


Fig.   274. — Melanoblastoma   of  the   tout. 

and  little  inconvenience.  He  has  been  treated  for  a  month  with  the 
x-ray  without  results  other  than  to  destroy  the  skin  about  the  tumor 
and  make  it  stand  out  more  clearly.  He  thinks  this  is  evidence  that 
the  ''roots"'  are  being  loosened.     His  general  health  is  good. 

Examination. — There  is  a  defect  in  the  skin  below  the  external 
malleolus  about  an  inch  in  diameter  (Fig.  274).  There  is  a  zone  about 
this  defect  from  which  the  epidermis  is  exfoliated,  likely  the  result  of 
the  x-ray  treatments.  There  is  a  globular  mass  protruding  through 
the  skin  defect.     This  mass  is  deep  red,  finely  granular,  elastic  and 


DISEASES    OF    THE    LOWER    EXTREMITIES  533 

clean  and  does  not  bleed  on  toucli.  It  appears  to  lie  independent 
from  the  skin.  The  lymph  glands  are  free  and  his  general  health 
good. 

Diagnosis. — The  tumor  is  one  which  progresses  slowly  but  grad- 
ually and  while  independent  of  the  skin,  tends  to  destroy  it.  It  must, 
therefore,  be  malignant.  True  sarcomas  developing  from  the  fascia 
do  not  occur  in  this  part  of  the  foot.  This  fact  together  with  the 
dry  glazy,  granulating  surface  characterizes  it  as  a  melanoma. 

Treatment. — Amputation  was  done  midwaj^  between  the  ankle 
and  the  knee.     Amputation  was  done  because  the  area  that  required 


^■J 


Fig.   275. — Spindle-celled  melanoblastoma  of  the  foot. 

removal  was  so  large  that  skin  grafting  would  have  been  required. 
The  patient  did  not  care  to  submit  to  this. 

Pathology. — The  gross  section  shows  the  tumor  to  be  uniformly 
pinkish  white  with  a  suggestion  of  bundle  formation  in  the  center. 
The  section  shows  a  spindle-cell  structure  in  the  center  portion  (Fig. 
275)  while  at  the  i^eriphery  the  alveolar  form  shown  in  a  previous 
case  may  be  seen. 

After-course. — A  year  and  a  half  after  the  amputation  the  inguinal 
glands  began  to  enlarge  and  reached  the  size  of  an  egg.  The  patient 
applied  iodine  vigorously  and  the  glands  regressed  almost  completely, 
contrary  to  my  prediction.  These  glands  did  not  enlarge  again.  In 
another  year  and  a  half,  however,  masses  could  be  felt  along  the  spi- 


534  CLINICAL    SURGERY    BY    CASE    HISTORIES 

nal  column.  These  gTadually  enlarged  and  attained  the  size  of  grape 
fruits  before  he  died,  some  four  years  after  the  operation. 

Comment. — At  the  time  of  the  amputation  the  growth  seemed  lo- 
calized, but  notwithstanding'  radical  treatment,  metastasis  had  al- 
ready taken  place.  The  peculiar  feature  of  these  tumors  is  that  de- 
spite the  obvious  fibrous  character  of  the  center  of  the  original  growth 
the  metastasis  was,  as  is  the  case  in  all  of  these  tumors,  by  way  of 
the  lymphatics.  This  case  presents  two  distinct  types  of  arrange- 
ment of  the  cells,  the  plain  fibrillar  and  the  alveolar. 

Sunvmary. — The  study  of  these  tumors  has  convinced  me  that  the 
component  cells  are  always  mesoblastic  in  origin.  In  some  of  the 
earlier  tumors  there  is  an  apparent  connection  between  the  cells  and 
the  epidermal  cells.  The  connection  is  that  of  secondary  contact.  It 
is  common  knowledge  due  to  tissue  culture  experiments  that  wher- 
ever there  is  a  fibrinoid  degeneration  of  the  connective  tissue,  whether 
from  cellular  growth  or  from  bacterial  infection,  epithelial  cells  tend 
to  follow  fibrin  bundles  now.  By  using  dyes  specific  for  fibrinoid 
bundles  the  epithelial  cells  can  be  traced  down  these  fibrils  into  the 
group  of  chroniatophore  cells.  The  use  of  the  path  of  metastasis,  by 
way  of  the  lymphatics,  as  an  argument  that  pigment  cells  are  epi- 
thelial is  wholly  unwarranted.  The  only  answer  required  is  the 
simple  statement  that  tumors  derived  from  chroniatophore  cells 
metastasize  by  way  of  the  lymphatics,  just  as  epithelial  celled 
tumors  do. 

This  group  of  tumors  besides  being  of  intense  scientific  interest, 
are  likewise  of  great  practical  importance.  If  their  nature  is  recog- 
nized in  their  incipiency  and  the  proper  treatment  applied  the  cure 
is  certain.  If  this  period  goes  unrecognized  and  improper  management 
is  instituted,  certain  disaster  results. 

CASE  8. — A  fanner  aged  fifty  came  to  the  hospital  because  of  an 
ulcer  on  the  sole  of  his  foot. 

History. — Three  years  ago  the  patient  noticed  a  black  spot  on  the 
sole  of  the  foot  in  front  of  the  heel.  It  has  grown  gradually  he  thinks. 
It  has  not  caused  any  pain.  The  secretions  annoy  him,  somewhat. 
It  is  because  of  its  persistence  that  he  seeks  medical  advice;  he  is 
afraid  it  may  become  a  cancer.  The  patient  has  been  a  heavy  drinker 
but  has  had  good  health  until  recent  years  when  he  began  to  have 
shortness  of  breath  and  pains  in  the  extremities. 


DISEASES    OF    THE    LOWER    EXTREMITIES 


535 


Examination. — An  ulcer  the  size  of  a  dime  is  located  as  seen  in  Fig. 
276.  Its  border  is  irregular  and  undermines  the  skin.  The  base  of 
the  ulcer  is  made  up  of  coarse  granulations  of  a  deep  red,  glistening 
color.  These  granulations  are  elastic  rather  than  dense  and  do  not 
tend  readily  to  bleed  on  manipulation.  The  reflexes  are  increased 
in  this  leg,  but  not  in  the  other.     The  sensation  in  the  affected  side 


Fig.    276. — Melanoblastoma   of   the   sole   of   the   foot. 


seems  to  be  markedly  lessened.  There  is  a  general  arteriosclerosis 
and  evidence  of  a  chronic  nephritis.  He  was  given  potassium  iodide 
internally  and  balsam  of  Peru  locally  and  instructed  to  return  for 
further  observation.  When  he  returned  after  two  months,  it  was 
noted  that  in  the  border  of  the  ulcer  small  granular  masses  seemed 
to  be  destroying  the  skin  by  growing  through  it  from  beneath.  The 
granulations  in  the  floor  of  the  ulcer  had  become  augmented  in  size. 
The  inguinal  lymph  glands  were  not  enlarged. 


536 


CLINICAL    SURGERi-   BY    CASE    HISTORIES 


Diagnosis. — The  slow  onset  and  indolent  character  of  the  ulcer 
together  Avith  evidence  of  disturbed  sensation  of  the  foot  caused  me 
at  first  to  think  of  a  perforating  ulcer.  The  chief  point  against  this 
diagnosis  Avas  that  it  did  not  perforate.  On  the  second  visit  a  close 
inspection  of  the  small  nodules  at  the  periphery  above  noted  and  the 
evident  proliferative  character  of  the  floor  of  the  ulcer  made  this 
diagnosis  untenable.  Besides  his  previous  habits,  the  facts  of  which 
I  had  obtained  in  the  meantime,  made  his  peripheral  nerve  disturbance 
capable  of  another  interpretation.  The  character  of  the  ulcer  and  its 
mode  of  spreading  fit  with  the  usual  characters  of  tumors  springing 


rsr-j^  •"-■'s^:^' 


Fig.   277. — Melanoblastoma   of   the  foot.     Alveolar   arrangement    of   spindle   cells. 


from  pigment  cells  and  the  diagnosis  should  have  been  made  at  the 
first  visit. 

Treatment. — The  ulcer  was  widely  excised  under  local  anesthesia. 

PatJiolofji/. — From  the  gross  appearance  it  is  apparent  that  the 
growth  is  independent  of  the  epidermis.  The  section  shows  it  to  be 
made  up  of  groups  of  oblong  cells,  without  chromatin,  arranged  in 
alveolar  groups,  but  Avith  a  distinct  intercellular  stroma   (Fig.  277). 

After-course. — The  wound  healed  readily.  In  a  year  and  a  half 
he  returned  Avith  a  series  of  nodules  in  his  calf,  a  fcAV  along  Hunter's 
canal  and  a  number  of  glands  in  the  groin.  A  year  later  nodules  ap- 
peared along  the  spine  and  in  six  mouths  more  he  Avas  dead.  The 
foot  remained  free  from  recurrence. 


DISEASES    OF    THE    LOWER    EXTREMITIES 


537 


Comment. — This  case  was  typical  for  this  class  of  affections.  The 
occurrence  along  the  course  of  the  lymphatics,  in  the  groin,  and  finally 
in  the  retroperitoneal  glands,  is  wholly  typical.  No  matter  what  the 
treatment  may  be,  or  how  early  instituted,  the  results  are  the  same ; 
inevitable  recurrence  in  the  lymphatics  of  the  leg,  the  groin  and 
finally  in  the  retroperitoneal  glands.  Local  excision  of  these  pre- 
serves for  them  the  use  of  their  legs  a  few  years.  Amputation  seems 
not  to  prevent  or  delay  recurrence.  I  have  seen .  patients  live  as 
long  as  eight  years  both  with  local  excision  and  with  amputation. 

CASE  9. — A  man  aged  fifty-four  was  sent  to  me  because  of  a  tumor 
of  the  groin. 

History. — For  a  number  of  months  the  patient  has  noticed  a  tu- 
mor in  his  right  groin.    Recently  it  has  been  developing  more  rapidly 


Fig.    278. — Melanoblastoma    of   the    foot. 


and  has  caused  considerable  pain.  He  consulted  a  surgeon  a  few  days 
ago  who  diagnosticated  infection  and  incised  the  larger  mass.  Some 
blood  flowed  out  but  nothing  more.  Otherwise  he  is  well.  He  has 
had  no  injury  or  other  trouble  with  his  foot  and  knows  no  cause  for 
the  swelling. 


538  CLINICAL    SURGERY    BY    CASE    HISTORIES 

Examination. — The  right  groin  is  occupied  by  a  bosselated  mass 
made  up  of  nodules  the  size  of  a  hickory  nut  to  that  of  a  walnut. 
They  are  located  for  the  most  part  below  Poupart's  ligaments.  They 
are  firm,  elastic,  somewhat  matted  together.  The  tumors  are  fixed. 
At  the  summit  of  the  larger  one  is  an  incision  from  which  bloody 
fluid  is  still  oozing.  In  Hunter's  canal  are  other  tumors  the  size  of 
hazelnuts.  These  are  not  painful,  but  discrete  and  hard.  On  the 
sole  of  the  foot  is  a  superficial  ulcer  made  up  of  a  dry  scaling  epi- 
dermis and  a  dry  granulating  mass  in  the  center  (Fig.  278).  This 
center  is  deep  red  in  color  and  resembles  the  granulations  in  an  old 
ulcer,  save  that  the  surface  is  drier.  About  the  border  the  new 
growths  seem  to  destroy  the  surrounding  skin  by  growing  up  through 
it.  The  affected  area  is  nowhere  tender  and  can  not  be  made  to  bleed 
by  manipulation. 

Diagnosis. — The  location  of  the  glands  below  Poupart's  indicates 
that  the  source  of  trouble  is  in  the  leg.  The  glands  in  Hunter's  canal 
prove  it.  The  duration  of  the  adenopathy  and  their  density  and  pain- 
lessness are  strongly  suggestive  of  secondary  malignancy.  The  find- 
ing of  the  granular  ulcer  in  the  sole  of  the  foot  confirms  the  suspi- 
cion. The  granular  base,  and  the  tendency  to  peripheral  extension 
marks  it  as  a  melanoblastoma. 

Treatment. — The  glands  were  treated  by  x-ray  without  result. 

Patltology. — The  patient  did  not  care  to  satisfy  our  curiosity  by 
allowing  us  to  excise  the  ulcer  to  permit  a  microscopic  examination. 

After-course. — The  glands  were  gradually  extending  when  last  heard 
from-. 

Comment. — In  this  case  the  patient  did  not  regard  the  condition 
in  the  sole  of  the  foot  of  sufficient  importance  to  mention  it.  En- 
larged glands  below  Poupart's  always  call  for  a  careful  inspection. 

CASE  10. — A  woman  aged  fifty-six  came  to  the  hospital  because 
of  an  ulcer  of  the  foot. 

History. — The  patient  first  noticed  a  small  black  spot  five  years  ago. 
It  grew  scarcely  at  all  for  a  long  time  and  it  is  only  recently  that  it 
has  annoyed  her  by  sticking  to  her  stocking.  Her  general  health 
has  been  good. 

Examination. — Under  the  tarsometatarsal  joint  of  the  second  toe 
there  is  a  defect  in  the  skin  presenting  to  view  a  deep  red,  firm  gran- 
ular area   (Fig.  279).     At  the  periphery  the  skin  seems  to  be  de- 


DISEASES    OF    THE   LOWER   EXTREMITIES 


539 


stroyed  by  the  granular  area  below  groAving  up  from  beneath.  The 
growth  is  quite  painless  to  irritation. 

Diagnosis. — The  slow  painless  growth,  its  irregular  border  and  tend- 
ency to  destroy  the  surrounding  epidermis  characterize  it  as  a  mem- 
ber of  the  chromatophore  group. 

Treatment. — Local  excision  was  done  by  an  intern. 


Fig.  279. — Melanoblastoma   of  the  sole  of  the  foot. 


Fig.  280. — Melanoblastoma  of  the  sole  of  the  foot. 


540  CLIXICAL    SURGERY    BY    CASE    HISTORIES 

PathoJogii. — This  specimen  shows  the  relation  of  the  growth  to  the 
surrounding  epidermis  nnusnally  well  and  is  worthy  of  careful  study. 
The  general  architecture  of  the  growth  is  distinctly  alveolar.  At  the 
periphery  the  epidermis  grows  out  in  long  finger-like  processes  sur- 
rounded by  round  cell  infiltration.  Between  these  finger-like  proc- 
esses are  large  ovoid  cells  containing  an  abundant  pigment.  It 
seems  to  be  these  pigment-bearing  cells  that  produce  the  tumor  growth 
(Fig.  2S0).  "Wliether  they  do  this  directly  or  stimulate  other  cells 
to  do  so  is  a  question,  for  tumors  of  this  type  are  seen  Avithout  there 
being  any  pigment  cells  present.  The  only  point  that  seems  well  es- 
tablished is  that  the  source  is  subepithelial.  The  question  of  the  ori- 
gin of  pigment  cells  is  foreign  to  the  present  discussion.  In  this 
case  the  pigmented  cells  seem  to  bear  a  close  relation  to  the  epithelial 
cells  and  in  many  instances  such  is  not  the  case.  Moreover  these 
tumors  grow  independently  of  the  epidermis  and  destroy  it.  The 
mere  fact  that  they  invariably  spread  by  lymphatic  metastasis  does 
not  enter  them  into  the  epithelial  group.  The  broader  view  that  pig- 
ment cells  are  mesoblastic  conforms  to  the  general  facts  in  oncology, 
however,  it  may  go  counter  to  some  concrete  facts  in  certain  sub- 
dermal  tumors. 

After-course. — The  patient  did  not  report  after  leaving  the  hos- 
pital. 

Cotnment. — The  area  excised  as  shown  in  the  figure  was  wholly 
inadequate,  yet  such  a  small  area  seems  sufficient  to  prevent  local 
return  and  metastasis  seems  inevitable  even  with  amputation. 

CASE  11. — A  man  aged  thirty-four  came  because  of  a  painful  area 
on  the  sole  of  his  foot. 

Historij. — For  several  years  he  has  had  a  hard  spot  on  the  sole  of  his 
foot  which  caused  pain  when  he  walked.  He  has  applied  corn  cures 
and  pared  the  surface,  this  together  with  the  wearing  of  a  bunion  ring 
has  made  walking  tolerable.     The  area  does  not  increase  in  size. 

Exaniiuafion. — Xear  the  lateral  border  of  the  great  toe  at  the  level 
of  the  tarsometatarsal  joint  is  a  thickened  area  in  the  center  of  which 
the  epidermis  is  thickened  and  in  part  defective  (Fig.  281).  The  de- 
fective area  is  5  x  7  mm.  In  the  center  is  a  pinkish  nodule  on  the 
surface  of  which  the  lines  of  the  plantar  epithelium  can  not  be  made 
out,  but  the  feel  suggests  epithelium.  The  border  is  made  up  of 
hard  epidermis  apparently  in  the  process  of  exfoliation.  Deep  pres- 
sure causes  some  pain.     Otherwise  examination  is  negative. 


DISEASES    OF    THE    LOWER    EXTREMITIES 


541 


Diagnosis. — The  painfulness  and  slow  growth  suggests  a  corn.  The 
ulcerous  appearance  as  though  a  granular  surface  were  seeking  exit 
suggests  a  melanoblastoma.  Since  there  has  been  little  change  in 
several  j^ears  and  because  the  outline  is  fairly  regular  it  is  accepted  as 
benign. 

Treatment. — The  area  was  excised  to  the  fascia  and  the  wound 


-Corn    of   the   sok-    of   the    foot. 


closed  by  subcuticular  sutures.  The  skin  was  avoided  by  the  sutures 
to  lessen  the  wound  pain. 

Pathology. — The  thickened  area  is  made  up  of  much  thickened  epi- 
dermis. There  is  no  tendency  of  the  epidermal  cells  to  invade  the 
deeper  tissue  and,  what  is  of  greater  importance,  there  are  no  chro- 
matophoric  cells  (Fig.  282). 

After-course. — Kecovery  has  been  permanent. 

Comment. — The  clisabilit}^  of  this  condition  is  often  very  great, 
greater  in  fact  than  in  the  malignant  condition,  for  the  thickened 
epidermis  causes  pressure  on  the  surrounding  tissues.     These  growths 


542 


CLINICAL   SURGERV    BY    CASE    HISTORIES 


are  essentially  epithelial  warts  which  project  through  the  surround- 
ing epidermis.  The  confusing  factor  is  that  the  epidermis  of  the  new 
growth  is  not  continuous  with  the  surrounding  epidermis.  Wide  ex- 
cision  is  sufficient   for   a   cure.     A  microscopic   examination   should 


Fig.  282. — riantai'  corn.     The  epithelial  connective  tissue  junction  shows  no  active 

proliferation. 

always  be  made  after  removal.     The  possibility  of  malignancy  must 
alwavs  be  Aveighed. 


CASE  12. — A  school  girl  aged  sixteen  came  because  of  a  growth 
under  the  nail  of  her  great  toe. 

Hisfory. — For  a  year  or  more  a  growth  has  been  coming  under  her 
toe  nail.  It  has  been  painless  but  its  size  interferes  with  the  wearing 
of  her  shoe. 

Examination. — Protruding  from  under  the  nail  of  the  left  great 
toe  is  a  mass  the  size  of  a  large  pea.  It  elevates  the  nail,  folding  it 
sharply  backward.  It  is  globular,  hard,  and  is  fixed  to  the  bone.  The 
skin  is  closely  attached  over  it   (Fig.  283). 

Diagnosis. — Its  density  and  firm  attachment  to  the  terminal  pha- 
lanx indicates  that  it  is  a  part  of  it.     Its  form  and  constricted  base 


DISEASES    OF    THE    LOWER   EXTREMITIES 


543 


is  evidence  enough  of  its  benign  nature.  Summing  up  these  charac- 
teristics, the  diagnosis  of  subungual  exostosis  is  unavoidable. 

Treatment. — The  attachment  of  the  growth  to  the  phalanx  was  sev- 
ered with  a  mastoid  chisel. 

Pathology. — The  mass  was  made  up  of  eburnated  bone. 

After-course. — The  patient  has  been  free  from  trouble  now  twenty 
years. 

Comment. — This  curious  condition  is  exceedingly  rare. 


Fig.    2S3. — Subungual   exostosis. 

CASE  13. — A  boy  four  and  a  half  years  of  age  was  brought 
to  the  hospital  because  he  limped. 

History. — The  mother  says  the  lad  jumped  from  a  chair  several 
weeks  before.  The  limping  began  gradually  and  increased  for  several 
weeks.  A  sprain  was  diagnosticated  and  the  foot  was  strapped. 
Marked  improvement  followed  this  treatment  and  in  several  weeks 
he  seemed  to  have  recovered  and  the  treatment  was  discontinued. 
Within  a  few  weeks  he  began  to  limp  again.  Because  of  this  a  more 
serious  condition  was  suspected.  The  lad  has  been  subject  to  fre- 
quent attacks  of  tonsillitis  following  which  he  developed  a  heart  in- 
fection. His  tonsils  were  removed  a  few  weeks  prior  to  the  beginning 
of  the  foot  affection.  Following  the  removal  of  the  tonsils  he  had 
a  high  fever  which  lasted  several  days. 

Examination. — The  lad  is  not  well  developed,  being  both  thin  and 
pot-bellied  with  some  other  evidence  of  rickets.  The  heart  is  di- 
lated, the  apex  being  in  the  axillary  line  and  a  systolic  murmur  is 
heard  everywhere  in  the  cardiac  region.  The  second  sound  is  ac- 
centuated. There  is  some  puffiness  of  the  whole  foot.  The  ankle 
joint  moves  without  limitation  and  without  pain.     "When  the  foot  is 


544 


CLINICAL   SURGERY    BY    CASE    HISTORIES 


grasped  pain  is  complained  of  in  the  instep.     The  tissues  seem  to  be 
indurated  and  feel  inflamed. 

Diagnosis. — Evidently  a  strain  does  not  account  for  the  trouble 
because  it  did  not  begin  at  once  after  the  alleged  trauma.  Once  im- 
proved a  sprain  should  not  light  up  again.  Koehler  described  a  dis- 
ease affecting  single  bones,  usually  the  scaphoid  of  the  left  foot.    This 


/ 


jMs'  sI  1 


Btt 


Fig.  284. — Koehler's  disease. 


DISEASES    OF    THE   LOWER   EXTREMITIES  545 

seems  to  suggest  such  a  condition.  The  x-raj-  showed  the  scaphoid 
of  the  left  foot  smaller  and  more  dense  than  the  corresponding 
foot  of  the  other  side.  (Having  lost  the  picture  of  the  case  under 
discussion,  I  venture  to  append  figures  obtained  from  a  case  in  the 
practice  of  Dr.  A.  S.  Risser — Fig.  284.) 

Treatment. — The  foot  was  again  supported  by  adhesive  straps  and 
the  lad  sent  to  the  country.  His  general  health  improved  much  and 
since  his  return  he  has  not  complained  of  his  foot.  He  is  much  im- 
proved, but  still  has  some  evidence  of  valvular  disease. 

Comment. — There  is  no  agreement  as  to  the  etiology  of  Koehler's 
disease.  All  cases  reported  have  been  in  boys.  Most  writers  believe 
that  it  is  of  traumatic  origin.  A  number  believe  it  is  a  compression 
fracture.  Rickets  have  been  present  in  a  number  of  cases.  The  an- 
swer to  the  traumatic  theory  is  that  in  some  cases  there  has  been 
no  trauma  and  in  a  number  of  cases  in  which  a  trauma  played  a 
part  the  impaired  function  did  not  manifest  itself  until  some  time 
after  the  receipt  of  injury.  In  this  case  the  disease  was  preceded 
by  the  removal  of  the  tonsils.  That  there  had  been  a  generalized  in- 
fection at  some  time  is  manifested  by  the  heart  affection.  The  only 
theory  that  harmonizes  with  all  the  facts  is  that  of  metastatic  infec- 
tion. The  irregular  outline  of  the  bone  and  the  increased  density  as 
noted  in  the  x-ray  harmonize  with  this  theory. 

CASE  14. — A  farmer  aged  forty-two  came  to  the  hospital  because 
of  stiffness  in  the  right  shoulder  and  right  foot. 

History. — About  one  and  one-half  years  ago  he  had  an  acute  sup- 
purative otitis  media  on  the  right  side  which  ruptured  through  the 
drum.  Four  days  later  the  right  foot  and  ankle  began  to  swell  until 
the  skin  was  tight  and  shiny.  Following  this  he  had  multiple  abscesses 
all  over  the  body,  especially  the  right  side.  No  abscesses  in  the  left 
leg  or  left  side  of  the  body,  but  several  in  the  left  arm.  The  skin 
abscesses  were  lanced  and  the  foot  was  lanced  in  a  number  of  places. 
The  right  shoulder  was  not  lanced.  He  was  treated  with  autog- 
enous vaccines  for  a  time  with  no  seeming  benefit.  The  abscesses 
were  three  months  in  running  their  course  and  he  was  in  bed  for 
several  months  after  that. 

When  he  got  up  his  foot  and  ankle  were  stiff  and  the  foot  extended 
and  turned  in.     It  has  remained  so  up  to  the  present  time.     The 


546  CLINICAL   SURGERY'   BY    CASE    HISTORIES 

shoulder  is  stiff  so  that  he  can  not  raise  his  arm  except  by  moving 
the  shoulder  with  it. 

Examination. — The  entire  right  arm  is  much  atrophied.  Scars  are 
seen  about  the  elbow  and  about  the  ankle.  They  were  barely  a  fourth 
of  an  inch  in  length — evidence  that  the  attendant  had  an  imperfect 
notion  about  the  opening  of  such  infections.  All  joints  are  movable 
save  the  shoulder.  This  is  ankylosed.  The  right  likewise  is  much 
smaller  than  its  fellow.  The  foot  is  in  marked  equinovarus  and  the 
ankle  is  ankylosed,  apparently  bou}'.  The  x-ray  pictures  show  the 
bones  of  the  foot  and  ankle  joint  have  undergone  a  bony  ankylosis. 
The  shoulder  joint  shows  a  fibrous  ankylosis. 

Treatment. — A  wedge-shaped  piece  of  bone  was  taken  out  of  the 
top  and  side  of  the  foot  with  no  attention  paid  to  joint  planes.  The 
foot  was  then  pulled  up  in  position  and  a  ten-penny  nail  driven 
through  the  os  calcis  into  the  end  of  the  tibia.  The  foot  was  then  held 
by  splints.  The  adhesions  in  the  shoulder  were  broken  up  while  the 
patient  was  under  ether. 

After-course. — After  two  weeks  the  nail  was  withdrawn  and  the 
foot  placed  in  a  plaster  cast  for  six  weeks.  At  the  end  of  this  time  the 
foot  was  found  firmly  united  and  in  good  position.  Two  years  later 
he  reports  the  foot  still  in  good  position  and  that  he  is  able  to  work 
without  hindrance.     The  shoulder  is  still  stiff. 

ConMiieiit. — Evidently  the  suppuration  involved  the  tarsal  as  well 
as  the  ankle  joint.  Possibly  the  resection  of  the  astragalus  might 
have  produced  a  partially  movable  ankle.  The  remainder  of  the  foot 
was  in  such  bad  position  that  any  sort  of  a  serviceable  foot  seemed 
all  that  could  be  hoped  for.  This  patient  is  an  excellent  example 
of  multiple  infections  from  a  distant  focus.  Had  the  joints  been 
opened  early  and  wide,  less  destruction  likely  would  have  resulted. 


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